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{ <br /> Waste Tire Su�y & Inspection Report lection Report Number <br /> 62State of California <br /> �� CIWMB 181(New 04104) . ► - 7 <br /> California Integrated Waste Management Board Survey Form Page 1 L- -- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- (J l Inspection Type (Fill one) { <br /> Site Suffix: I r ' �J <br /> 1 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local l - If Referral,choose referral type(Fill one) <br /> Identifier: , ` /(' �.(� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name / (- Inspected By - <br /> Inspector <br /> Physical Address <br /> .- <br /> Street <br /> f Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM AM <br /> ' O PM O PM <br /> L,1VJ ' <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all <br /> The Count(Wholthat apply) (Fill all that apply) (Fill all that apply) <br /> Te/PTE) _7 <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude m • 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <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 I 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred t 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 /> 0 0 Other: § ----- <br /> Comments <br /> Inspection Form Included: 0 mow <br /> Comments Included: 0 --- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E X�A-Mj P L'J E j' 1 i a j 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />