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Waste Tire Su- y & Inspection Repo �r)o�Ri; StateBof California Surve Form Pa e 1CIWMB 181(New 04/04) Y _California Integrated Waste Management Board ------.--------------..--. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- ' �' � - m 'Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q).Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J (f­� / y ! I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> _ <br /> Physical Address l <br /> 144 l T~ - <br /> Street <br /> Inspection Date <br /> City State ZlP Code Time in Time Out <br /> Business Rep Title Q AME LFTI <br /> Q AM <br /> O�MeCount <br /> (Whole/PT v/ �` 0PM _ QPM <br /> ' , <br /> Operational Status Tire`Type Business Role Storage Type <br /> 6 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Gl Passenger Q Generator O Outdoor <br /> F-1-10 ' <br /> 0 Closed 0 Altered <br /> GPS Latituded I O Hauler O Indoor <br /> C O Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> 0 Service Station O Hauler Q Agriculture Q Shredder ® Other (_ I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation 0 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 Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> ® Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 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 Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> ® O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> Inspection FM-10ed ' <br /> Comments Included: Q -- <br /> Business Rep's Signature Phone Number Irtspeetor's Signatures Phone Number <br /> YA t <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � �'� A ��t P I L I El 1112 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />