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rtes_ Waste Tire Survey & Inspection Report Inspecti nVepP m%e bState . ■ <br />ooQ. ClWM ofCaliforniaSurvey Form -gage 1 i - � a <br />CIWMB 181 (New 04104) <br />California <br />Integrated Waste Management Board <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID - <br />Site Suffix: <br />I <br />3 <br />6 <br />J <br />0 <br />� <br />Inspection Type (Fill one) <br />(lb Routine Q Re -inspection Q Referral Q Observation <br />Local <br />Identifier: �c�` �Q <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />// <br />Inspected B <br />P Y Inspector <br />F3 / <br />Physical Address <br />I .3 A 3 9 .S' '5z/daf'��a I <br />Inspection Date / O / <br />Street <br />7 <br />Time In Time Out <br />0 AM Q AM <br />City State ZIP Code <br />Business Rep Title <br />M 0 PM 0 PM <br />Operational Status <br />(Fill one only) <br />Tire Type <br />(Fill all that apply) <br />Business Role <br />(Fill all that apply) <br />Storage Type <br />(Fill all that apply) <br />Tire Count (Whole/PTE)IJz]10 <br />® Active <br />® Passenger <br />® Generator <br />Q Outdoor <br />Q Closed <br />Q Altered <br />Q Hauler <br />is indoor <br />0 <br />GPS Latitude <br />—_ 0 <br />Longitude - f I ! <br />I . F �� <br />Q Inactive <br />Q Planned <br />Q Truck <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader ® Dismantler Q Tire Derived Fuel <br />I <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 I I <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility JENFORCEMENT STATUS <br />JRIMIHAULING AND MANIFEST REQUIREMENTS <br />f VQ Extension <br />Q Notice Oiolation <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 iM e <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 �xn <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 / C-IWMB 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 In Compliance - No Violations <br />Q Q Other: § <br />Comments <br />-ei- L� �a -6C� r 1 / %/� / eft ��✓y r �e . �%^�'C/'T ���cr r C <br />y1ox . YJ tea° Yy J �� 40_� <br />inspection Form Included: Q/ <br />9 <br />Y6.8 _0 <br />Comments Included: Q <br />Business Rep's Signature Phone Number Inspector's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct: Incorrect: X A M P L E[ 11[21]3 62081 <br />■ While Copy: CIWMB Yellow Copy: Operator Pink Copy. LEA ® ■ <br />