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° = Waste Tire Sy & Inspection Repor Inspection Report Number <br /> State of CaliforniaCIWMB 181 04/04) Ai in` f/� Q /� <br /> Calif Integrated Was eeManagement Board Survey Form - Page 1 1 1 S V ' L V Vj <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- / ( � 1 m Inspection Type (Fill one) -W INNIIIIII i <br /> Site Suffix: L1 lA `1 J L, �' , ® Routine Q Re-inspection Q Referral Q Observation <br /> Local , I If Referral,choose referral type Fill one <br /> Identifier: _ �l off t �� i r 1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l! Inspected By Inspector <br /> Physical Address - L_ <br /> VJ q I <br /> Street <br /> Inspection Date <br /> City — -� State ZIP Code Time In - Time Out <br /> Business Rep Title 1 AM O AM <br /> + 1 W ' — 0 P W ' L 0Pf,l <br /> Operational Statusre Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> V (Fill one only) .(Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger, ;I Q Generator Q Outdoor <br /> O Q Closed Q <br /> O ' Altered <br /> GPS Latitude Q Inactive Q Truc <br /> LOHauler Q Indoor <br /> Longitude se <br /> r <br /> Planned <br /> Business Type (Fill all fhb ap 'y " <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 - <br /> Q Q - Q Notice Of Violation Q Extension <br /> 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 <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 /> � i <br /> 4— — <br /> [pection Form Included: <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> X �j� <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X A ,��l P L E1 6:208 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />