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Waste Tire Su. . a & Inspection Reportflnspection Report Number <br /> State of California Y p <br /> CIWMB 181(New 04/04) Survey Form - Page 1 { 2 - 10 2 5 8 3 <br /> California 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: i 0 � � � 7 � � � 0 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 FacilityName <br /> 1 Inspected By Inspector <br /> Physical Address <br /> Inspection Date L> v <br /> 5 Iry v+�C.�'o� - °l 3Zv <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> `r- O PM O PM <br /> 1.00 ZC�., iAA �-,y <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 7— 0 b (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator 8 Outdoor <br /> O Q Closed Q Altered <br /> ii GPS Latitude ® Hauler Q Indoor <br /> O Q Inactive 4 Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber J <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other l ry•\� �; a,�� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Q - - Q Notice Of Violation Q Extension <br /> 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 ® 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWfvIB <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 ® 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/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 ® In Compliance - No Violations <br /> Q Q Other: § <br /> - Comments vo-L,�M�'T�t L <br /> Q. <br /> �� A <br /> �t ow` —C4-V�b,oV� lj U�t�y�'� t yl S <br /> V0.^ SO�.�w`7'v'S �c���c o - <br /> Inspection Form Included: Q <br /> Comments Included: Q [<.\,J <br /> �` 11 <br /> Business Rep's Signature Phone Number Insp tor's Signat a Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E X I A M I PL 1 2�i1 62081 <br /> White Copy:CIWMB Yellow Cop?Operator Pink Copy:LEA <br />