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Waste Tire S ey & Inspection Repo*..-.-- .. Report Number <br /> State of California f t . --- --i 1. <br /> CIWMB 181(Nw 04/04) <br /> California Integrated Was eeManagement Board Survey Form - Page 1 ...1 1J-, 0 ' <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profit-; ,�, "' `✓w^m ,aa`� tf= w';. ,-r el�"' T" wJf�'", )a rm w4 lam' # ~rw.z<, .wws Inspection aim r „ru*"m- <br /> - Ins tiType (Fill one) <br /> Site Suffix: I � �J 7 ( � i I / I - I p <br /> SiteTPIi <br /> Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - - - <br /> Inspected By Inspector <br /> Physical Address - I <br /> t <br /> Street m <br /> - Inspection Date <br /> • J <br /> City State ZIP Code ! Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> 'OPM FTI : F 0 <br /> PM <br /> Operational Status Tire Type Business Role Storage Type <br /> The Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> . ^� <br /> GPS Latitude O Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude <br /> p - Q Planned Q OTR Q End-Use Q Container <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Service Station <br /> Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - ---------- ------- ------- - Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 Responsible Entities Complying with Manifesting Requirements Date m / [11 / [11 <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q I Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years I <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q I Other: § I <br /> Comments <br /> Inspection Form Included: Q — <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X jl�, r V A ,010, 9. 1 2 :. <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />