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spection Report Number <br /> Waste Tire Surve & Inspection Re ort <br /> State of CaliforniaI <br /> CIWMB 181(New 04/04) Survey Form - Page 1 1 2 - 1 Q 1 3 5 L L P <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 /> r�Site Suffix: / ( / , )I ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �l �I}t! �b� + 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Street <br /> r Inspection Date L' •^lair <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O0 AM PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> r' (Fillone only) (Fill all that app ,, ( (Fill all that apply)Y)I Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude O (9 Closed 0 Altered 1I <br /> IGPS 0 Hauler 0 Indoor <br /> C 0 Inactive 0 Truck <br /> Longitude - _ 0 Planned 0 OTR 0 End-Use 0 Container <br /> II <br /> Business'Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 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 /> Notice Of Violation 0 Extension <br /> -- —._.-- ----- - <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0,In Compliance - No Violations <br /> 0 0 Other: § _-. -- <br /> Comments <br /> f <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> �. . . <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X . <br /> �f rX;,r .� 62081 <br /> M� =` i_ a <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />