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® 0?1%,Waste Tire Su & Inspection Report spection Report Number <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 # 8 - 10 13 3 0 5 <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. I C�� J l // ✓ I - �� Q Routine Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: <br /> 0 CHP OCIWMB OCom taint OEducational Visit OOther <br /> Business or Facility Name ✓ <br /> Inspected By Inspector <br /> • i - <br /> Physical Address <br /> L�_ . <br /> Street <br /> Inspection Date <br /> 1I- _____ In Time Out <br /> City State ZIP Code Time-_.ime _s— <br /> Business Rep Title � AM O AM <br /> 0 PM 0 PM <br /> _j <br /> Operational Status Tire Type Business Role Storage Type <br /> Tare Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fillall that apply) <br /> " ® Active Q Passenger Q Generator Q Outdoor <br /> lO Q Closed <br /> GPS Latitude Q Altered m Q Hauler Q Indoor <br /> ht� Q Inactive Q Truck <br /> O <br /> Longitude - FT F Q Planned Q OTR O End Use Q Container <br /> a;npiy) <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 /> HAULING AND MANIFEST REQUIREMENTS V A I NTS I Q Notice Of Violation Q Extension <br /> Q O 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 /> O (5) 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O 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 Q 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 /> O O Other: § _ ------ - <br /> Comments 1 4 <br /> _ <br /> ti <br /> r <br /> Inspection Farm Included: Q <br /> Comments Included: Q _ _ I <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X J�, Mii:' lj <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />