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® � Wa§te Tire Su <br /> 8t InSpeCtlOn ReporfiInspection Report Number��� - ftly <br /> jn{ `f�� `ni )j'`�y }f'''ly 7 , <br /> 1, p�Q '". <br /> CIWMBof.California Survey Form - Page 1 V � V 0 V V' 4 f f <br /> CIWMB 181(New 04/04) <br /> Califo is Integrated Waste Management Board -- ' <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> t"+A rre�"+.IM, -1%7, <br /> nr i;, Y <br /> �rl �^„'.- fil18� ;�' ""f.+,.^'�+", t *u r u,.t ! ,�'v�v^,! ..a._.W.': ....�M' <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: �����: T� _,_1Q 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 Inspected By Inspector <br /> Physical Address <br /> I I <br /> Street Inspection Date <br /> I <br /> State ZIP Code Time In Time Out <br /> _ - <br /> ® AM 0 AM <br /> L �'�_� 0 PM O <br /> PM <br /> Business Role <br /> Operational Status t <br /> t <br /> Tire Count(Wh01@/PTE (Fill one only) t� IFI (Fill all that apply) 1yMt4tp� l �� <br /> " k r <br /> Q Active ���b r", �'�� �+,r Q Generator <br /> ---- — - —. _ O <br /> Q <br /> Closed <br /> GPS Latitude ��� � rt „a 1tu�r'" Q Hauler I rQ 4 iat �' <br /> r <br /> inactive <br /> t t <br /> Q Iti <br /> M yN� RO rtq� � � p <br /> Longitude 0 Planned <br /> o°4fr0 <br /> End Use Crt� <br /> r„; �, a. � �,” ry �",�, i r+2"� �r ,� f��„ � :" r �*�,,,,t;a w",�� ✓"a45 r"� ,� ��ti*, "� " <br /> `:" ��",��."�"T +�'" 'itlF 1 .'�;� ,r w;P ��"dt r t r h HS a � e� r'a�i,���r`M � r�r ,...Ilv ;�6 vti;" t 7� ?triv'���'a+�a.�J�3.4�;?���Su✓a""';��r .,�"�"�«"v,.��. �,�.��'-'�,:�1.,_.'�' �..'fir";..,�,h".�° <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 /> V j A 'i,HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT)' <br /> Q Q 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 I CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators iQ In Compliance - No Violations <br /> Q Q Other: § - --'- -- <br /> Comments <br /> Inspection Form included: Q <br /> Comments Included: Q -_ <br /> Business Rep's Signature Phone Number inspector's Signature Phone Number_ <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X A����" <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />