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rWaste Tire SuGby & Inspection Report _Inspection Report Number ■ <br /> ■ k10 State of California <br /> CIWMB181(New 04/04) Survey Form - Page 1 1 2 - 1 0 0 0 4 2 7 <br /> Management Board <br /> California Integrated Waste Manage -- — <br /> Part A Surfey BLUE OR BLACK INK PEN <br /> — ' ' �� <br /> W + <br /> ITPin- Inspection Type (Fill one) <br /> Site Suffix: '—' � 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 /> '_- <br /> Street ` <br /> Inspection Date <br /> 'r 1C /1 <br /> i ;� J <br /> City � State ZIP Code Time In Time Out <br /> Business Rep Title AM 0 AM <br /> =1 Q PM O PM <br /> 4 <br /> � �Operational Status ( Business Role Storage Type <br /> f (Fill one only) (Fill all that apply) (Fill ail that apply) <br /> Tire Count(Wholell <br /> Active & Generator ( Outdoor <br /> 0 Q Closed , <br /> GPS Latitude w, Q Hauler Q indoor <br /> D Q Inactive Q <br /> -- Q Container <br /> Q End Use <br /> Longitude — ,�--- �� Q Planned Q OTF ' <br /> iii 999 III <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 /> Q Used Tire Dealer Q Auto Body (a 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 /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <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 /> O Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> Q O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 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 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> OO 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Other: § <br /> O --- ---- ---- <br /> Comments <br /> Inspection Form Included, Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector s Si n turew .__ Phorrg NurrrbI r,_.��� <br /> . _ <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X IV i l MP'X'A F L E It 121 6481 <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br />