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nspection Report Number <br /> ., <br /> Waste Tire Su & Inspection Report <br /> 'IDIIBrt State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 iJ <br /> California Integrated Waste Management Board .... 1 --l-- - i <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> ro- <br /> TPID- ,�; t // Inspection Type (Fill one) <br /> Site Suffix 0 Routine 0 Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ' t ' <br /> �( !� ! I j I t(%? 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name + i.� Inspected By Inspector <br /> Physical AddressEJ ( – 1, <br /> F-i T <br /> 1 <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time InTime Out <br /> Business Rep Title Q AM7--j— Q AM <br /> —_ <br /> _� ' Q PM Q PM <br /> Operational Status:! Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that app (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> „ . <br /> 0 Active 0 Passenger 9, 0 Generator 0 Outdoor <br /> O <br /> _ (a Closed 0 Altered <br /> GPS Latitude -T– - 0 Hauler 0 indoor <br /> _ O 0 Inactive 0 Truck <br /> Longitude – F=-LL-1 <br /> 0 Planned 0 OTR End-Use 0 Container <br /> ---------- <br /> Business Type ( t <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 /> 0 Notice Of Violation 0 Extension <br /> V A ',HAULING AND MANIFEST REQUIREMENTS i <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 -Tire Program ID Number from CIWMB <br /> 0 0 § p 14 CCR 18459.3-Retention of Comprehensive TriLogsLogs <br /> 3 ears y - (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip s within 90 days <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 /> 01 0 Other: § _ <br /> Comments I J/ <br /> 1 [ (.'"i it I (,( /�,I , ' —/ <br /> Ut <br /> f lt'.7 t.'1 <br /> 0 <br /> Inspection Form Included: 0' r <br /> Comments Included: 0 _ <br /> Business Rep's Signature Phone Number inspector's Signature Phone Number <br /> ,�,'"; <br /> X � �r`�i I ll 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � �'iiL 1112131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />