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Iection Re ort Number <br />Waste Tire Sur-�y &Inspection Reportnspp . _ <br />California State of California <br />Survey Form - Page 1 1 5-1000652 <br />CIWMB 181 (New 04/04) <br />Integrated Waste Management Board <br />Part A SLa BLUE OR BLACK INK PEN <br />,� <br />r,„°, a r-r/,N ,r �"•, ;f vww. k <br />z r <br />li <br />.�' . ri�fW.a�a ”„ t _., w.. <br />TPID - Inspection Type (Fill one) <br />Site Suffix: I I ' [`�Tc4�_F �- 1 - Routine 0 Re -inspection 0 Referral Observation <br />Local i If Referral, choose referral type Fill one <br />Identifier �,- , ti^ `t v `�0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name Inspected By Inspector <br />'• [. 1 [ - <br />Physical Address ?S - \ <br />e <br />Sfreef p / � <br />/ L�1 <br />Inspection <br />Date <br />State ZIP Code <br />i Time In Time Out <br />Business Rep TitleAM 0 AM <br />•[E�PM S •� 0 P <br />- ; Operational Status Business Role 4 age Type <br />Fill one only) <br />( y) W Ian , � (Fill all that apply) ;(Fill all that apply)', <br />Active , ® Generator 0 Outdoor <br />0 Closed m+ <br />GPS <br />Latitude µ�>Na <br />0 Hauler 0 Indoor <br />--FI.FT0 0 inactive T °r <br />Longitude Planned O'0TR° " End -Use Container <br />Q New Tire Dealer <br />(2) Auto Repair <br />0 Trucking Fleet <br />0 Government <br />0 Retreader <br />( Used Tire Dealer <br />0 Auto Body <br />0 Car Dealer <br />0 Collection <br />0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A I HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 1 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 0 <br />Other: § <br />Comments <br />Dismantler 0 Tire Derived Fuel <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />I <br />Compliance Deadline <br />Date / <br />m m El <br />(Required for NOV or EXT) <br />INSTRUCTIONS ON BACK Correct: 16 Incorrect; ; '�,,,' Fri � � 1 62os1 <br />"!'' I <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />