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f9 <br /> Waste Tire Su y & Inspection Reportlnspection Report Number ■ <br /> L6.w�G��s State of California € <br /> B 181 New 04/04 I _ -+ <br /> CIWMB I I Survey Form - Page 1 f r ! 0 I <br /> California Integrated Waste Management Board - - -- -- - —-- - <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> T <br /> Built <br /> r <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix ^ ' Yru r i ' Q Routine Q Re-inspection O Referral Q Observation <br /> Local r1 - , `` If Referral,choose referral type(Fill one) <br /> Identifier: & O CHP Q CIWMB Q Complaint O Educational Visit O Other <br /> Business or Facility Name <br /> l Inspected By Inspector <br /> h sical Address - (c <br /> treet <br /> Cr ,.� '\ .� Inspection Date <br /> .. <br /> R - Sfate ZIP Code Time In Time Out _ <br /> Business Rep _ i:., 1/r 71(&/,Y <br /> � ' Title /'tl ( 1 _. Q AM Q AM <br /> � QPM QPM <br /> Q_ — -�-"-" -'"I — - — Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply), <br /> ,`+ Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude O O Closed 0 Altered <br /> !N 0 Hauler 0 Indoor <br /> -- - Q Inactive 0 Truck <br /> O <br /> Longitude - T ., � Q Planned 0 OTR End Use 0Container <br /> M�..,. ,,,.. , <br /> Business Type (Fill all that <br /> O New Tire Dealer O Auto Repair O Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O 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 0 Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> 0 0 Other: § - <br /> Comments t' <br /> r> �� - - -- <br /> Inspection Form Included: QI <br /> Business Rep's Signature Phone Number Inspector s Slgn ; <br /> Comments Included: - <br /> ature _J Phone NumbeY , <br /> � <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:i Incorrect: >( �,. �/ i N� d'rp,.P° 1_ 1, Z 3'1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />