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Waste Tire Su Ins ort �s'pe I p umer <br />=ia �Y & Inspection Re p <br />State of California <br />CIWMB 181 (New 04104) Survey Form - Page 1 11 1140803 <br />California Integraied Waste Management Board <br />Part A - Survey_ BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - Inspection Type (Fill one) <br />Site Suffix: .Z ® 0 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local If Referral, choose referral type (Fill one) <br />Idc ntifier: y y.� % Z�� � c'>tiJ � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name Inspected By Inspector <br />Physi • Address <br />Inspection Form Included: 0�, / --- <br />Comments Included: ® <br />Business Rep's Signature Phone Number Inspector's Signature PhoneNumber <br />e--- - -rm--- <br />INSTRUCTIONS ON BACK tre,� enr .;� i �. zW.� 62081 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA ® r <br />— _ <br />Inspection Date <br />` <br />S / / 0 <br />0 Generator <br />CX '�S.26Sr <br />G �S <br />Latitude O <br />0 Closed <br />0 Altered <br />0 Hauler <br />Time In <br />Time Out <br />:mousiness Rep <br />Title <br />Sty <br />v ® <br />®AM <br />(� <br />C� ® AM <br />® 0 <br />O <br />Longitude — <br />Q PM <br />/ Q PM <br />1 0 End -Use <br />Operational Status <br />Te i <br />ire Typ <br />Business Role <br />Storage Type <br />Tire Count Whole/PTE <br />Dismantler t� Tire Derived Fuel <br />(Fill one only) <br />(Fill all that apply) I <br />(Fill all that apply) <br />(Fill all that apply) <br />Inspection Form Included: 0�, / --- <br />Comments Included: ® <br />Business Rep's Signature Phone Number Inspector's Signature PhoneNumber <br />e--- - -rm--- <br />INSTRUCTIONS ON BACK tre,� enr .;� i �. zW.� 62081 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA ® r <br />— _ <br />It Active <br />0 Passenger <br />0 Generator <br />® Outdoor <br />G �S <br />Latitude O <br />0 Closed <br />0 Altered <br />0 Hauler <br />0 Indoor <br />0 Inactive <br />Truck <br />O <br />Longitude — <br />0 Planned <br />0 OTR <br />1 0 End -Use <br />0 Container <br />Business Type (Fill all that apply) <br />— <br />0 New <br />Tire Dealer 0 Auto Repair ®Trucking Fleet 0 Government 0 Retreader <br />Dismantler t� Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service <br />Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEME"-,T STATUS <br />V <br />I A <br />HAULING AND MANIFEST REQUIREMENTS <br />(Notice Of Violation 0 Extension <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />-i <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />0 <br />0 <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date% <br />/MAO / CJ <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />,� <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXT) <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 Referred / CIWMB Enforcement <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />® <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 in Compliance - No Violations <br />0 <br />1 0 <br />1 Other: § <br />Comments <br />Inspection Form Included: 0�, / --- <br />Comments Included: ® <br />Business Rep's Signature Phone Number Inspector's Signature PhoneNumber <br />e--- - -rm--- <br />INSTRUCTIONS ON BACK tre,� enr .;� i �. zW.� 62081 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA ® r <br />