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Waste Tire Sy 8c Inspection Repo Inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 Z 4 - 10064 '20 <br /> California Integrated Waste Management Board - - <br /> Part A- Survey <br /> BLUE OR BLACK INK PE <br /> Business Profile Inspection Details <br />} TPID- Inspection Type (Fill one) <br /> Site Suffix: Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q.Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address -U,--( <br /> - I 1 1 _ <br /> Lr i x L_._.__—� � <br /> Street p <br /> I� <br /> /State ZIP CodeIns Inspection Date <br /> I Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> QPM -._ 0P <br /> __—J I �\i ° - _ <br /> 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> f 0 Q Closed Q Altered <br /> GPS Latitude - • Q Hauler Q Indoor <br /> I J <br /> 0 Q Inactive Q Truck <br /> Longitude - FTT� - � _ 1 i i, __1 <br /> Q Planned Q 01-R Q End-Use Q Container <br /> Business Type (Fill all that apply) ',1 <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 Q Other b. ` <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> _. <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 Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 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/CIWMB Enforcement <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 Q In Compliance - No Violations <br /> Q Other: § <br /> Comments <br /> Inspection Form Included: <br /> Comments Included: D; <br /> - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X moi " �"m�" r"NI I <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> I <br />