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.W:. <br /> `Y Waste Tire Sur.,,q & Inspection Report inspection Report Number <br /> iirwil State of California - <br /> CIWMB181(New04/04) Survey Form - Page 1 ( 1i <br /> 03 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> In Details <br /> TPID- -2 (3, � (� 1 - Inspection Type (Fill one) <br /> Site <br /> Site Suffix: 7 Q-Routine 0 Re-inspection a Referral 0 Observation <br /> Local n If Referral,choose referral type(Fill one) <br /> Identifier: ',;i 'C ��U t,r i I('6a ✓l `i 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit Other <br /> Business or Facility Name Tr Inspected By Inspector <br /> t - <br /> 1 <br /> Physical Address l ' <br /> - <br /> T-1 / ' It i /I VCl - <br /> Inspection Date <br /> State ZIP Code <br /> S I Time In roft) <br /> Time Out <br /> Business Rep Title 40 AM 0 ANI <br /> 0 PM I � / (, O PM <br /> Operational Status Tilwfpe Business Roleorage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply)'I (Fill all that apply) . ll all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O � Closed 0 Altered I <br /> GPS Latitude m F-TTF17 0 Hauler 0 Indoor <br /> O 0 Inactive Truck <br /> "Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: XJ�, E X1 A MI P I L I El 11123 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />