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Waste Tire Su4 & Inspection Report _ ispection Report Number <br /> State of California <br /> CIWMB181(New 04/04) Survey Form - Page 1 1 7 - 1 0 06 5 9 5 <br /> California Integrated Waste Management Board <br /> Part A- Survev BLUE OR BLACK INK PEN <br /> TPID- � � -E � Inspection Type (Fill one) <br /> Site Suffix � <br /> : ���3 f (D Routine O Re-inspection Q Referral Q Observation <br /> Local �^ Y,.-� If Referral,choose referral type(Fill one) <br /> Identifier: f? �� @ r Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> ef <br /> Physidw Address <br /> Street,, Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 P — I � __T 0 P <br /> Operational Status 71re Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f. (Fill one only) (Fill all that app (Fill all that apply) (Fill all that apply)' <br /> } Active 0'-Passenger Q Generator Q Outdoor <br /> GPS Latitude <br /> O Q Closed a Altered <br /> Hauler 0 Indoor <br /> � O Inactive Q Truck <br /> Longitude O0 Planned 0 OTR <br /> +1 O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government 0 Retreader 0 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 (E) Hauler 0 Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q 0 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 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O 0 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 a 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 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 /> 0 0 Other: § <br /> Comments <br /> 1 r � <br /> ✓�: -4 lr <br /> Inspect it arm Included: <br /> Comments Included: Q =- <br /> ter_ <br /> Business Rep's Signature Phone Number Inspectors Sign <br /> /X r I 620$1 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � EA MTP <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />