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La <br /> -Waste Tire Su. _ ay & Inspection Reporblnspection Report Number <br /> State of California <br /> �} <br /> Cto,IWMB181(New04/04) Survey Form - Page 1 1 1 - 0 0 1� 7 <br /> 6 6 <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` C/ C Inspection Type (Fill one) <br /> Site Suffix: ® Routine 0 Re-inspection O Referral O Observation <br /> Local _ >� If Referral,choose referral type(Fill one) <br /> Identifier: S Com- Cr_ �UM O CHP O CIWMB 0 Complaint 0 Educational Visit Q Other <br /> Business or Facility Name %� <br /> Inspected By Inspector <br /> Physical Address _ — a <br /> Inspection Date <br /> Time In Time Out <br /> Bus*ness1Rep� Title O AM _ O AM <br /> PM l"� 5 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 ® Active * Passenger ® Generator ®Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers- Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years y <br /> 0 0 <br /> 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f CIWMB Enforceme <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities ^w <br /> O (#) 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators °"°' <br /> Q In Compliance No Violations <br /> O O Other: §f� <br /> Comments <br /> Inspection Form Included: Q (� <br /> Comments Included: Q — - — —- <br /> Business Rep's Signatur Phone Number Ins ector's Signature Phone Number <br /> --_.___.__._-------_--___-�--_• / / � - 62081— <br /> INSTRUCTIONS ON BACK 'I Correct: Incorrect:XV/ I X hh P L �j 1 , 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA <br />