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Waste Tire Sur,.:y & Inspection Report Inspection Report Number <br /> W7State of California <br /> 1o <br /> CIWMB 181(New 04/04) Survey Form - Page 1 i 9 0 3 d <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile s N Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Z - t`j t ® Routine O Re-inspection O Referral O Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: `jA;", �w� � ��� O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address , C, rp t_ �� L� <br /> 525 Inspection Date 1 D \ L <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 1 vN3 - 1 "y <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill cne only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f Q -,ctive O Passenger O Generator O Outdoor <br /> O * Closed O Altered <br /> GPS Latitude O Hauler O Indoor <br /> 0 O -active O Truck <br /> Longitude - O clanned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) - - <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - --- --------------------- <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O OO Notice Of Violation O Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Rec-lirements Date / <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O <br /> O 014 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> a. <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Eriforcerr) t <br /> , <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Comp liance - NoY Vlolat ons <br /> O O Other: § - - - <br /> Comments l <br /> iInspection Form Included: O <br /> Comments Included: 0)1(- <br /> aess <br /> BuSAS ature P one Number Insp ctor's Signature Phone Number <br /> —____.--.------^_— — 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: { X A M� P L 12 3 <br /> `; White Copy:CIWMB Yellow Copy:Opere:.r Pink Copy:LEA <br />