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Waste Tire Survey & Inspection Report Inspection Report Number <br /> 1� 1- State of California <br /> CIWMB181(Now 04/04) Survey Form - Page 1 1 4 1 0 1 4 8 2 8 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business s Profile ;Inspection Details <br /> TPID- r inspection Type (Fill one) <br /> Site Suffix- p `� J— Q \ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> PhisiC; Ad <br /> dressidress <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 P 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> o Q Closed Q Altered <br /> CIPS Latitude � O Hauler QIndoor <br /> Q Inactive Q Truck <br /> Longitude _ Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® 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 FacilityENFORCEMENT STATUS <br /> 'V=I A I HAt1LINCi AND MANIFEST REQUIRfxMEl1$. _ Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Compliance Deadline. <br /> Q Q PRC§42956-RegistrationlDecal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pate <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMi3 <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV orF�CT} <br /> I <br /> O O <br /> 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 Reforred 1 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 <br /> Other: § Inofttpllattge !,-.:No Violations <br /> Comments <br /> ,�,t,c,,w, � �f ,; >W�i � ►4 �UVB " �y ��`�s <br /> Inspection Fo��40 "ri'n ` d ��� �'�' 5Commenusine s Rep's Signa ure Phone Number jInspe s Sign a Phone Number <br /> i 62 <br /> INSTRUCTIONS ON BACK Corl' Qiv, i' tFloi!t`QG�i C � 111,­ <br /> ' L 1j rY yZ 3l �hK�ea <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />