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Waste Tire SAW & inspection Repoi nspection Report Number <br /> State of <br /> CIWMB <br /> Survey Form - Page 1 t - 3 0� <br /> ^--=; CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: I 2 -7T 6 5 - / ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> I / � <br /> Physical Address <br /> St eet <br /> _ f + Inspection Date > j <br /> ----- <br /> State ZIP Coop Time In Time Out <br /> Business Rep Title : I <br /> O AM EE : m O AM <br /> 0P 0P <br /> Operational Status T Type Business Role Storage` ype <br /> Tire Count (Whole/ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that appl. <br /> ® Active Q Passenger Q Generator j1d:o O Q Closed Q Altered <br /> GPS Latitude m • Q Hauler Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler i 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 (D 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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 / 7 <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 /> Inspection Form Included: O W r <br /> Comments Included: Q --- <br /> Business Rep's Signature Phone Number Inspector's Signature. _ Phone Number <br /> X -IE 6201 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X A DIY P 1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />