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® Waste Tire Sur a,,& Inspection ReportOnspection Report Number <br /> .. State of California <br /> CIWMB 181(New 04/04) ry [7 <br /> 9 <br /> california Integrated Waste Management Board Survey-Form Paye 1 V! 1„f � 4 7 9 9 <br /> Part A- Survey Inspection Details – --- <br /> Business Profile <br /> Y BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I 2 `7 TI L--) f Routine <br /> Q Re-inspection p Q Referral Q Observation <br /> Local _ f–^ 1 If Referral,choose referral type(Fill one) <br /> Identifier: 'L Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -- <br /> Inspected By Inspector <br /> Physical Address , r – j� `".j c <br /> Street <br /> Inspection Date / l / �` <br /> rick- - ! S <br /> Y State ZIP Code Time In Time Out <br /> Business Rep Title f 0AM O AM <br /> 0 P --- ' � QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> ( Y) ( apply)only)Fill one° 1 Fill all that a I (Fill all that apply) (Fill all that apply) <br /> Tire Count{INholelPTE� <br /> (0 Active Q Passenger Q Generator Q Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPS Q Hauler Q indoor <br /> O Q Inactive Q Truck <br /> Longitude Q Planned Q OTR Q End Use Q Container <br /> Business Type (Fill all"that'apPIY) <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 (P 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 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 Ve-hicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FU <br /> 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 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance No Violations <br /> Q Q Other: § <br /> Comments l– _ <br /> Inspection Form Included: Q' <br /> I <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ® INSTRUCTIONS ON BACK Carred:® Incorrect: X A 7, <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />