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Waste Tire Sully & Inspection Repo nspection Report Number <br /> State of California <br /> CIWMB 181(New 04/04) - l�/ �j ,t 2 <br /> California Integrated Waste Management Board Survey Form Page 1 _ f. .�_ <br /> Part A- Survey r BLUE OR BkACK INK PEN <br />} TPID- - m Inspection Type (Fill one) <br /> Site Suffix: _ O Routine 0 Re-inspection O Referral Q Observation <br /> I J <br /> Local /- If Referral,choose referral type(Fill one) <br /> Identifier: O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name r <br /> Inspected By Inspector <br /> __i <br /> Physical Address J — D/T <br /> j --- <br /> Street - <br /> Inspection Date <br /> Citv State ZIP Code Time In Time Out <br /> Business Rep Title ]OAM O AM <br /> 0 P 0 P <br /> Operational StatusTire Type _ Business Role Storage Type <br /> Tire Count (Whole/PT (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active O Passenger g Generator Outdoor <br /> � <br /> GPS Latitude O Closed 0 Altered <br /> � . <br /> O Hauler Indoor <br /> 0 O Inactive 0 Truck <br /> Longitude — O Planned O OTR O End-Use CQptainer <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government 0 Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer 0 Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder () Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> ® O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> t9 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> O 0 Other: § <br /> Comments <br /> Lil <br /> �spection Form Included: <br /> O , , —�_— <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X hh I E X A P I L E 1 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />