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Waste Tire Su, .ey & Inspection Report Inspection Report Number ■ <br />= ��= State of California <br />CIWMB 181 (New 04/04) Survey Form - Page 1 11- 1127473 <br />California Integrated Waste Management Board BLUE OR BLACK INK PEN <br />Part A - Survey - - -- -- - - ---- - — - - <br />------------------- <br />Bu siness Profile Inspection Details - - -- <br />TPID - Inspection Type (Fill one) <br />Site Suffix: �— 3 (� p� l Routine Q Re -inspection Q Referral Q Observation <br />Localc c \ tIf Referral, choose referral type (Fill one) <br />s <br />Identifier: 'V\ wck� �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name Inspected By Inspector <br />CL- l O 1 AL �vnbu l <br />Physical Address <br />Business Rep(� \\ Title <br />f' R I r <br />Tire Count (Whole/PTE) , <br />GPS Latitude <br />O <br />Inspection Date <br />L l / <br />'J Q / <br />O <br />Time In <br />Time Out0 <br />AM <br />1 <br />90 AM <br />l <br />i PM <br />l <br />O PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />® Passenger <br />® Generator <br />0 Outdoor <br />Q Closed <br />� <br />Q Altered <br />Q Hauler <br />Q Indoor <br />Q Inactive <br />Q Truck <br />Q End -Use <br />Q Container <br />Longitude - Q Planned _ Q OTR - <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader <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 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />Q Q i PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q Q PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q Q PRC § 42956 - Registration/Decal in Vehicle <br />Q Q 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q Q 14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q Q 14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q Q 14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q Q 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <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 Q Other: § <br />Comments Q - L, _ _ _ _ <br />Dismantler U Tire Derived Fuel <br />c' (fe r L C6 e— /C . <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />® in Compliance No Violations <br />Inspection Form Included: U / . <br />00 <br />Comments Included: Q - Ls - - --- <br />- - - - - - <br />Bus ep's Signature Phone Number In C., Signature Phone Number <br />--- �` 6208 <br />INSTRUCTIONS ON BACK I Correct:9 incorrect:, (;� E X Am 1 2 3 <br />l�_— --- <br />White Copy: CIWMB Yellow Copy: Operator Pink Co : <br />