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Waste Tire SLf► & Inspection Repor ,spection Report Number <br /> ri7 State of California <br /> CIWMB181(New 04/04) <br /> California Integrated WasteManagementBoard Survey Form - Page 1 8= 1 n ? 2 8 3 8 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> ITSite _Suffixr/ (, - Inspection Type (Fill one) <br /> Site : Routine Q Re-inspection Q ReferralQ Observation <br /> Local <br /> If Referral,choose referral type(Fill one) <br /> Identifier: r, r i1 <br /> I <br /> OCt f 1 1-t+ '� i s o\ `� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Faculty Name I Inspected By Inspector <br /> Physical Address <br /> La <br /> ` �,• ylI' <br /> Street 4 ) n L Inspection Date <br /> I ( I <br /> City State ZIP Code Time In Time Out <br /> Business Rep. Title � : QAM � : � QO AM <br /> O <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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> WL <br /> GPS <br /> Latitude m O O Closed Q Altered <br /> O Hauler Q Indoor <br /> O ® Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> Q I O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 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 lit`.. -i ✓l` �!l fGl� /t C`-(:(; %( Y)t) r�IC! <br /> VI <br /> l' <br /> � )f TN'•' �°t . ,-�a L' (:�Ts [ �.i{1�{ I1.:r _t )`0t(t(� :� " IlF t (( �'C� <br /> f(;t. I i %1 `( < � ,i( v� r� ilr, ac � U;-. . fY1 +1 It��� �.,A".,�-"�r <br /> Inspection Form Included: Q <br /> Comments Included: <br /> O''Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E X I A.hP L F t 2 3! <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />