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... pection Report Number <br /> Waste Tire S y & Inspection Repo <br /> State of California <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board Survey Form - Page 1 A-.0--0 6 4 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> ,Ig <br /> g,7� <br /> T OR, vlfj� <br /> "I"g <br /> Inspection Type (Fill one) <br /> Site Suffix I EE 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> TPID <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or'Facility Name Inspected By Inspector <br /> Physic al Ad dress <br /> Street <br /> Inspection Date <br /> city State ZIP Code Time In Time Out <br /> Business Rep Title E) AM _T 0 AM <br /> 0 PM F 0 PM <br /> Operational Statu Business Role Storage Type <br /> (Fill one only) (Fill all that apply) <br /> 0 Active Generator <br /> Now=c, <br /> 0 0 Closed <br /> ude 0 Hauler <br /> 0 inactive <br /> 0 x4 <br /> Longitude 0 End-Use <br /> 0 Planned <br /> 0 New Tire Dealer 0 Auto Repair Trucking Fleet Government 0 Retreader (Z) 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 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M <br /> 0 0 14 CCR§18459.1 (a) (b)(c)-Tire Program I D Number from ClWMB (Required for I NOV or EX I T) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <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 i CIWMB Enforce ent <br /> !n <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 <br /> (D In, Com Hance No,Violations- <br /> 0 0 Other: § <br /> Comments <br /> 62081 <br /> Correct <br /> INSTRUCTIONS ON BACK Incorrect: X X A E <br /> White Copy:CJWMB Yellow Copy:0 pe rator Pink Copy:LEA <br />