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ns Report ort Number <br /> Waste Tire SUN* & Inspection Report'- p _ p <br /> State of California <br /> SpA CIWMB181(New 04/04) Survey Form - Page 1 - 1006636 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A Surve , <br /> "S t"p �ql •'1z l�j �'""" ""�,9b ," li ., +'_..1—. '�Y�WJ..u,�u' Ukt J�.,. ', ' <br /> TPID- Inspection Type (Fill one) <br /> f Site Suffix: ` 1 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> I l - <br /> m' Street Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title . O 0 AM <br /> PM r <br /> � �, r O PM <br /> �f <br /> I- t- Operational Status Tire Type Business Role Storage Type <br /> (Fill all that apply) <br /> I (Fill one only) (Fill all that apply)�, (Fill all that apply) ( , <br /> Tire,Count ount(WholelPTE) <br /> If Q Active `- Q Passenger Q Generator Q Outdoor <br /> o` Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> D Q Inactive Q Truck <br /> Longitude - Q Planned Q QTR Q End-Use Q Container <br /> Business Type (Fill a"I I lat 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 /> ---- <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 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> QQ 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 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 /> Inspection Form Included: Q' <br /> Comments Included: Q _ <br /> Baseness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _�.. 62081 <br /> INSTRUCTIONS ON BACK <br /> Correct:* Incorrect: "v Iw t <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> � ■ _ <br /> f <br />