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ection Report Number ■ <br /> Waste Tire Se Inspection Repor <br /> -State of California <br /> CIWMB181(New04/04) Survey Form - Page 1 - 1 0 1 0 5 3 5 <br /> California Integrated Waste Management Board <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> 01111 <br /> Business Profile <br /> TPID- f Inspection Type (Fill one) <br /> Site Suffix: � f <br /> Routine Q Re-inspection Q Referral Q Observation <br /> If Referral,choose referral type(Fill one) <br /> Identifier: Q Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name �T <br /> � Inspected By Inspector <br /> I / <br /> Physical Address <br /> I � <br /> Street <br /> r <br /> Inspection Date � <br /> City State ZIP Code Time In f Time Out <br /> ELBusiness 'Rep Title 0 AM 0 AM <br /> O PM 0 PM <br /> L 1,t <br /> u Operational Status Tire Type ' Business Role Storage Type <br /> i (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> b 0 <br /> ( Q Active QPassenger Q Generator Q Outdoor <br /> GPS Latitude <br /> O o Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> (V Inactive Q Tr I r <br /> Longitude — FF� , I I I I 1 Q Planned Q OTR Q End Use Q Container <br /> Business Type <br /> fl c'll` l <br /> Q New Tire Dealer AutoRepair 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 ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I 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 /> 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 / M / m <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 Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I 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 /> 0 0 Other: § _ <br /> Comments j Jul(% <br /> t o 1,,� r <br /> ''c. Ct ei,1 <br /> "it fr. 1 )+0�� O'd u,, Lr> (t,�- rfa� ��j }YV 1 - t!�,���j; ( /' "! I vi <br /> r �� { r <br /> Inspection Farm 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 dim,- A.Ali,i=' 11,L; <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />