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nspection Report Number <br />Waste Tire Sur _y & Inspection Report <br />SCIWMB 181 (New 04/04) tate of California Survey Form -Page 1 j V jV j <br />California Integrated Waste Management Board <br />Part A - Survev BLUE OR BLACK INK PEN <br />TPID - <br />Site Suffix: <br />Local _ <br />Identifier: <br />:I`I1-1 (1 i <br />ra <br />( C' (.t y',. (,' <br />Inspection Details <br />Inspection Type (Fill one) <br />(b Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name (' Inspected By Inspector <br />Physical Address - T <br />Vk, r <br />Street .JI <br />Inspection Date <br />City State ZIP Code Time in Time Out <br />Business Rep t / TitleM 0 AM 0 AM <br />-I -J O PM 0 PM <br />L_ 'Operational Status ire Type Business Role Storage Type <br />(Fill one only) all that apply) (Fill all that apply) (Fill all that apply) <br />Tire Count (Whole/PTE) <br /># Active assenger, 0 Generator 0 Outdoor <br />O Altered <br />GPS Latitude 0 Closed m , 0 Hauler 0 Indoor <br />D 0 Inactive 0 Truck <br />Longitude - r) oi..,.,o.A r) r)TQ 0 End -Use 0 Container <br />U Government <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer ® Collection <br />0 Service Station 0 Hauler 0 Agriculture 0 Shredder <br />0 Retreader <br />0 Crumb Rubber <br />(� Other <br />0 Dismantler 0 Tire Derived Fuel <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 <br />Other: § <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />0 In Compliance - No Violations <br />Comments/4(t 1 I tt E ` i( 1 >' l /(H /f C1 - ` ( L <br />� t/( � 1 ✓( <br />J ,J <br />f t1r , / ,/. Vtt��•tJF�( v .���1y1 }b, �; te•, f C - 1 ;r � ro - I. -_t <br />�Y C1 1 C i 1 � 1 t t: t� j j � t <br />+t` f ( i% i,r'�y L({ !l Ill Vic('} i!1 '!.t'( �11 Lf;(/ -4 �) <br />ispection Form Included: 0 <br />Comments Included: 0 <br />Business Rep's Signature Phone Number Inspector's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct: Incorrect: X J i ,X4 I A, M [PTL 62081 1 L � z 3 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />