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® r Waste Tire SuM� & Inspection Report0spection Report Number <br /> State of California <br /> CIWMB181(New 04/04) Survey Form - Page 1 I1 - 1141166 <br /> California Integrated Waste Management Board _... <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPIG ) <br /> Site SuffixInspection Type (Fill one)- <br /> : 1 7( <br /> - r+_ 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 i <br /> Physical Address <br /> i <br /> Inspection Date ,7-- ,-71 / <br /> � f <br /> ia[o Zig t ode 1 <br /> ......... ........ <br /> Time In Time Out <br /> Business Rep Title 0 AM l Q AM <br /> { OPM Vi ( DPM <br /> ...�_�- <br /> Operational Status Tire Type Business Role Storage Type <br /> TireK9unt(V�hole/PTE) (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> a <br /> a,. Q Active Q Passenger � Generator Q Outdoor <br /> O Q Closed Q ,herd <br /> CPS Latitude Q Hauler Q Indoor <br /> . — Q Inactive 0 Truck__..... O <br /> Longitude Q Planned 0 amQ End-Use Q Container <br /> 11 <br /> Business`rype_.(Fill ail that appy)<.. <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> el <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 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> _____ __. ---- ---:--- Q Notice Of Violation O 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 Ill Ill <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§1.8459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 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 O In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> ��t-;r �lil >��� ")���� ►Girl �[�1 l� �1 i `�� ; , � C'�`�' � ; , <br /> U Ll fir - <br /> Inspection Form Included: Q <br /> Comments Included: Q _ <br /> Business Rep's Signature Phone Number Inspector's Signature Plmno Number <br /> INSTRUCTIONS ON BACK Correct:is Incorrect: X r � ; A. V.,� 62081� � , i �, <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />