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Waste Tire Suy & Inspection Repornspection Report Number <br /> ® �<iA �- State of California F •} <br /> °M 9 Survey Form Page 1 t 1 2 2 <br /> California Integrated Waste Management Board - <br /> CIWMB 181(New 04/04) Y ("� 4...._.-,�, —__ --_—-------_--. <br /> PartA Survey `� BLUE OR BLACK E <br /> 1 .� <br /> H :;�:J>��,' 'il 5m✓'", r: �i +�i,iJ�' ' tr,! k ; r t;'. <br /> .� "» �� _v ��G .�. ez refs,.. .C.�,.'.✓.�. <br /> TPID- �)' Inspection Type (Fill one) <br /> Site Suffix: . (i r yJ ' 9 Routine O Re-inspection O Referral O Observation <br /> Local -- _^1 If Referral,choose referral type(Fill one) <br /> Identifier: `-'� '� <br /> J _ O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name ed InnspectBy Inspector <br /> ted <br /> Physical Address <br /> t f w <br />"` Stre J Inspection Date / ! EE <br /> S. City / State ZIP Code Time In Time Out _ <br /> Business R/ep / ! Title 0 AM 0 Am <br /> 0 PM 0 PM <br /> ; Operational Status Tire Type Business Role Storage Type <br /> )' (Fill one only (Fill all that apply)' (Fill all that apply) (Fill all that apply)', <br /> E �� S Active O Passenger O Generator O Outdoor <br /> G O Closed 0 Altered <br /> Latitude <br /> GPS O Hauler O indoor <br /> li --1 G O Inactive a Truck <br /> # <br /> 7, t O O O End Use O Container <br /> Longitude <br /> g Planned OTR <br /> Bc 'P,.,ess Type (Fill all that apply} <br /> ,» Grp�. <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 /> c� <br /> O Service Station O Hauler O Agriculture O Shredder O Other I <br /> Part B - Inspection of,Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> r V A HAULING AND MANIFEST REQUIREMENTS <br /> O Notice Of Violation O Extension <br /> O O PRC§4295'0-Waste Tire Hauler Registration and Transport of Tires <br /> -Contracts with Registered Waste Tire Haulers. <br /> O O PRC§429�3 9 Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O <br /> 14 CCR§'18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§,18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB M / m / m <br /> (Required for NOV or EXT) <br /> O O 14 CCR§118459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§'18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 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 O In Compliance - No Violations <br /> O O Other: §, <br /> Comments <br /> ml <br />( . <br /> I <br /> Inspection Forth Included: 0, <br /> Comments Included: O <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X "w``, EiEk <br /> ® While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> ■ <br />•t <br />