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® ="= Waste Tire Su, ,3ey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB 181(New 04/04) ! - a 0 0 6 5 � 8 <br /> California Integrated Waste Management Board Survey Form - Page 1 I I y1'./► �},/� <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile - - -- - - <br /> Inspection Details — <br /> TPID- Inspection Type (Fill one) <br /> Site Sffi <br /> ux: ` D - ,� <br /> --- ® Routine Q Re inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S Nv V CL� <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - - - _ <br /> Inspected By Inspector <br /> Physical Address � G� _ <br /> Lr 1-,�4- <br /> v\3 r4A-1- <br /> X'� �� Inspection Date l+ D / 3. / u <br /> �� <br /> Business Rep Title Time In Time Out <br /> O AM Q AM <br /> �(hA � �`t'iW-e. �t�• J (!�lPM o 2 5- QPM <br /> - - - --Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> > > 1 V b <br /> - - - Q Active © Passenger Generator Q Outdoor <br /> GPS Latitude O Q Closed Q Altered <br /> Q Inactive Q Truck Q Hauler ® Indoor <br /> O <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) - - <br /> Q New Tire Dealer QAuto Repair Q Trucking Fleet Government Q Retreader QDismantler <br /> 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityENFORCEMENT <br /> _ - <br /> STATUS <br /> V � A HAULING AND MANIFEST REQUIREMENTS-------------- <br /> 0 <br /> EQUIREMENTS -----------Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q ' Q PRC§42956-Registration/Decal in Vehicle Compliance Deadline <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q I Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV, <br /> �ori nsz 4 <br /> Q Q 114 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 Haulersele(rred.CIWMB ofCe en, <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q n (Other: § <br /> In Compliance m Xo'Violations <br /> Comments `A <br /> t70 <br /> Inspection Form Included: Q % <br /> Comments Included: Q <br /> -- - - - -- - <br /> siness Reps Signatur P Number In pec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK LCorrect: Incorrect (� A5� L I 2 3� 62081 <br /> White Copy:CIWMB Yellow Copy:Operatcr Pink Copy:LEA <br />