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E. Waste Tire SL - :y & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB181(New 04/04) Survey Form - Page 1 1 6 - 10 0 6 6 3 71 <br /> California Integrated 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: _ Q Routine Q Re-inspeotian�. Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: , Q CHP Q CIWMB Q Complaint QAducational Visit Q Other <br /> I Business or Facility Name <br /> Inspected By Inspector <br /> r; <br /> Physical Address <br /> Street <br /> - - Inspection Date - <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> / QPM 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE. 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude d <br /> O Q Inactive Q Truck Q Hauler Q Indoor <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> IL <br /> ,,.. <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 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 /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m m <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> pection Form 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 / ,"ml r' � L <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />