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Us1L1U9UU61 <br /> i= :i Waste Tire Sway & Inspection RepoState ln=m <br /> ee .i ClWM 181(CalifornlaSurvey Form - Page 1 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / L D - O / Inspection Type (Fill one) <br /> Site Suffix: ? IS Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��,� � ;-f 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Street C., <br /> Inspection Date <br /> City �1 State ZIP Code Time In Time Out <br /> Business Rep Title O PM O / Q PM <br /> T Operational Status Tire Type Business Role Storage Type <br /> Tire CountWhole/PTE I 2 : (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ( ) Active ® Passenger ® Generator ® Outdoor <br /> �I 1 . I I I I D Q Closed 0 Altered <br /> GPS Latitude I I 11�f <br /> D Q Inactive O Truck Q Hauler Q Indoor <br /> Longitude — _ Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ID Auto Repair. Q Trucking Fleet O Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder O Other I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AN_01 MANIFEST REQUIREMENTS <br /> o Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice of Violation Q Extension <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC•§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/C-IWMB Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q1 Other: § <br /> Comments „/zrG�� ../, _ ,�.��c✓ f�Gr.��y Gt.4�� , <br /> Inspection Form Included: Q Gy ( / p .� /Zvp, <br /> Comments Included: Q 6-a� � - ZQ/ J- ^7� A �Sv~ <br /> Business Rep's Signatur Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Co rec• Incorrect: �� � 62081 <br /> � X � !►� P •LE ' i !23 <br /> White Copy: Yellow Copy:Operator Pink Copy:LEA <br />