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. :: Waste Tire S ey & Inspection Re O nspection Report Number <br /> State of California � � /" � <br /> CIWMB 181(New 04/04) Survey Form - Page 1 0 - 1 u/-4 0, 0" 6 Z5 D <br /> ca <br /> i lfornia 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: ` J to Z C7 0 Routine 0 Re-inspection ® Referral 0 Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: S L h -�v`=` (�tv� l�.�n 0 CHP ® CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> A-1 *fv,,.,. T t�c-.( _ I t <br /> Physical Address <br /> Inspection Date / / <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> Ei Z V �PM v 3 ® PM <br /> Operational Status Tire Type ype Business Role Storage Type <br /> Tire Count (WholelPTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ; -� <br /> ® Active ® Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered li <br /> GPS Latitude ® Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use ® Container —I <br /> Business Type (Fill all that apply) <br /> - New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXE <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 ® 14 CCR§18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance No Violations <br /> 0 0 Other: § <br /> Comments t� I •i t'`��(/tel .;vim 1N�� � �'�t:�/w• `7�`tiG U�� � �,:C.�rci� �CS�.� �^_{_, <br /> Inspection Form Included: <br /> Comments Included: 01 -- — <br /> Business Rep's Signature Phone Number Ins ctor's Signature Phone Number <br /> I 62081---- <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X "I- ;IE A Ah P! L E' 11 2 31 <br /> �� White Co CIWMB Yellow Copy:Operator Pink Copy:LEA <br />