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Waste Tire Surk & Inspection Report nsspection Report Number_ <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A- Surve <br /> ' "" - Inspection Details <br /> — <br /> _ @ Inspection Type (Fill one) <br /> TPID- _ _ <br /> �� � � <br /> Site Suffix:_1-._ _4-_ _ (� Routine Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: , C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Ph sica <br /> y I Address <br /> ,street ! <br /> i Inspection Date Ld Business R Z <br /> — State ZIP Code Time In Time Out <br /> l0 AMI T <br /> 0 AM <br /> Rep Title Ll_ .___! O PM I <br /> � __�,_, PM <br /> �t Operational Status Tire Type Business Role 5tor ge Type <br /> (Fill one only) (Fill all that apply)' (Fill all that apply) ,(Fill all that apply), <br /> Tire Count(Whole/PTE) ! �� <br /> Active 0 Passenger Q Generator Q Outdoor <br /> O j Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> LLI L -. Q Inactive Q Truck <br /> _ 1C <br /> Q End-Use *Q Container <br /> Longitude - I Q Planned Q OTR <br /> ,Business Type:(Fill all tha# <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 /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part <br /> Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V <br /> A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> h Registered Waste Tire Haulers. <br /> PRC 42953-Contracts wit Compliance Deadline g <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <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 GeneratorsQ In Compliance - No Violations <br /> Q 0 Other: <br /> Comments <br /> Inspection Form Included: Q' <br /> Comments Included - - - <br /> QLBusiness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> - - - 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X1 L{ 1 ; 2.I i <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />