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Waste Tire Sfty & Inspection Repoli, Inspection Report Number <br /> �_-- State of California <br /> 'am CIWMB181(New 04/04) Survey Form - Page 1 1 2 - 1 0 1 3 5 06 <br /> California Integrated Waste Management Board <br /> - - BLUE OR BLACK INK PEN <br /> PartA Survey <br /> Business Profile Inspection Details - <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 L 3 �1 A C`V ` Q Routine ® Re-inspection Q Referral Q Observation <br /> Local ` 1 ` If Referral,choose referral type(Fill one) <br /> Identifier: 5 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address Y <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM _ O AM <br /> \r� J 3 \ S ®PM C O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) I Fill all that apply) (Fill all that apply) <br /> Is Active 0 Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q 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 Q Hauler Q Agriculture Q Shredder Q 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 /> V ' Q Notice Of Violation Q Extension <br /> Q 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 /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV orDCT) s <br /> !" C <br /> Q I 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years . <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers efeRed/CIWMB= In <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 <br /> .®,In. Compliance No Vlolat!o s <br /> .. <br /> 10 0 i Other: § - — --- - <br /> Comments <br /> '' y3 �.�.�.�,� \ ��S �'h �►`14��� �� A r�< < �,�ti(.�«s A <br /> -- <br /> �C- �tti'�u o��f 5 ati5 (,ow-.a ��lv�c j- l.l�-�_ ( t'C-�S <br /> Inspection Form Included: Q <br /> Comments Included: O <br /> ( -----— - <br /> - - <br /> Bus ness Rep Signature Phone Number Ins ctor's Signatu a Phone Number <br /> - - - - - - <br /> INSTRUCTIONS ON B K ('Correct. Incorrect '` '';' E X A'M P L E 1112 3 62081 <br /> =----- — - <br /> White Copy:CIWM8 Yellow Copy:Operator Pink Copy:LEA <br />