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t <br /> r <br /> =: Waste Tire S & Inspection Reporftspection Report Number <br /> EL'ES State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 �4 - 10 1 3 3 <br /> • California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> I TPID- I � Inspection Type (Fill one) <br /> Site Suffix: 1-7 �. CJ [�7 - / @ Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> _ Inspected By Inspector <br /> li ( p I _ <br /> Physical 9ddress 7 <br /> Z ' - <br /> Street <br /> `-� Inspection Date <br /> City State ZIP Code I Time In Time Out <br /> Business Rep Title : m O AM m : m O AM <br /> PM <br /> Operational Status ire Type Business Role Storage Type <br /> �� (Fill one only) Fill all that app (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE 6 <br /> LMMM 1 ® Active Q Passenger (#Generator Outdoor <br /> O Q Closed Altered <br /> GPS Latitude � • Q Hauler rdoor <br /> O Q Inactive Truck <br /> Longitude i <br /> Q Planned <br /> OTRm Q End-Use Container <br /> at <br /> QNew Tire Dealer 0AutoRepair Q Trucking Fleet QGovernment QRetreader <br /> Q Dismantler Q Tire Derived Fuel i <br /> 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 Facility ENFORCEMENT STATUS <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 m / m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 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 Q Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> — - - <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X �7x A o-,t P � E1 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />