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Waste Tire Sur & Inspection Report spection Report Number N <br /> s7.7i State of California 7 fy tfy <br /> CIWMB 181 04/04) <br /> California Integrated Was eeManagement Board Survey Form - Page 1 t 1 0 t 7 3 4 2 L <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ' �� ^1 f.l I l; Q Routine Q Re-inspection Q Referral Q Observation <br /> Local ': i, If Referral,choose referral type(Fill one) <br /> Identifier: f( ` / Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U Inspected By Inspector <br /> Physical AddressF1 \)f – 1 <br /> j -- -- <br /> v I <br /> Street / <br /> Inspection Date �; f 1 / ? =J <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> � I 0P � 0P <br /> i Operational Status rTire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 (Fill one only) (Fill all that apply)! (Fill all that apply) (Fill all that apply) <br /> Ijj Active Q Passenger Q Generator Q Outdoor <br /> r—i <br /> -- — �O Q Closed Q Altered <br /> Latitude <br /> GP$ 1 <br /> _7 Q Hauler Q Indoor <br /> __ IJ Q Inactive Q Truck <br /> Longitude – Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that 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 /> 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 <br /> M / M / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive 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 /> Inspection Form Included: O <br /> Comments Included: <br /> Q'Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ -- <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X Ak V I STA h4 P L. E i 1 62081 C <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />