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■ `'70SS� & Inspection Repor I. Inspection Report-Numbe_rWasiforna _ <br /> — ■ <br /> CIWMB 181(New 04/04) <br /> - Page 1 , 1 7 1 0 0 65 14 <br /> Survey Form <br /> California Integrated Waste Management Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> 4r`, 7Y.tib*'✓" r ' ��i' ' A <br />} TPID- ` ` - Inspection Type (Fill one) <br /> Site Suffix: I� ' <br /> I i 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 Inspected By Inspector <br /> Physical AddressF)T ` t <br /> .. <br /> � i <br /> ,Street G T <br /> Inspection Date m <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title Q AM AM <br /> . I f QPM . � 0 P <br /> 1_- <br /> Operational Status Tire Type Business Role <br /> , (Fill one only) (Fill all that appld (Fill all that apply) <br /> Tire Co6nt ,Whole/PTE) MLL <br /> ,r @ Active Q Passenger i Q Generator Q Ot #oor <br /> QClosed Q Altered <br /> GPS Latitude �„� Q Hauler Q Indoor <br /> _ O Q Inactive QTruck <br /> Longitude - LLj <br /> Q Planned Q OTR Q End-Use Q Container <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 A !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/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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> I <br /> Inspection Form Included: Q <br /> 7� <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 i-µ A M P L I e 2 i, a <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA <br />