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■ „ Waste Tire Sur# & Inspection Report spection Report Number ■ <br /> State of California S + `� '` ", - <br /> CIWMB181(New 04/04) Survey Form - Page 1 1 n U <br /> California Integrated Waste Management Board ! <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile ,'' 'tl�l� :,Inspection Details <br /> ( TPID- f --r Inspection Type (Fill one) <br />}9 Site Suffix: t` I•' ' (a) Routine O Re-inspection O Referral O Observation <br /> Local if Referral,choose referral type(Fill one) <br /> 4 <br /> 'r Identifier: or, t ( O CHP O CIWMB O Complaint O Educational Visit. O Other <br />' tr Business or Facility Name Inspected By Inspector <br /> _ L_L? <br /> Physical Address j %i ` i k +',- <br /> Street r <br /> ( Inspection Date <br /> L ' r <br /> C�'ih State ZIP Code Time In Time Out <br /> Business Rep Title '' AM O AM <br /> r <br /> 0 PM <br /> / <br /> t f f { Fl <br /> OM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> aQ Active O PassengerO Generator O Outdoor <br /> —(— ... O Closed O Altered <br /> Latitude <br /> O Hauler O indoorGPS 1-f-] . E[= , O Inactive 0 Truck <br /> O <br /> Longitude — O Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O 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 /> - O Notice Of Violation 0 Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date O / m / m <br /> O O 1.4 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR 18459.3-Retention of Comprehensive Trip Logs for 3 Years ----- - - <br /> i I <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§184-62-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O O In Compliance - No Violations <br /> O O Other: § - <br /> Comments <br /> i <br /> _.. <br /> L <br /> Inspection Form Included: O <br /> Comments Included: O <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> -Ti _ 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X \/ � �P„ I_I L y <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />