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® Waste Tire Sulwy & Inspection Reporte Inspection Report Number ■ <br /> State of California <br /> h. <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I 1 1141276 <br /> California Integrated Waste Management Board --- -- ----- --- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ! Inspection Type (Fill one) <br /> Site Suffix it , ( ! Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> i <br /> Identifier: (� �� u N (1 � � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address - �i (� <br /> t l i <br /> .�...- � ......�..� .... . _ .:._._ u.}_1�,�1.\_. ...ek_.....__..._ ._....._.._` - <br /> Inspection Date'M <br /> tett� 7 <br /> Time In Time Out <br /> Business Rep Title O AM ! ' O AM <br /> /�j� Q PM <br /> U t !Vl� Q-� O P M <br /> _ .. <br /> (AiOperational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all tl,�at apply) <br /> Tire Gaunt(Whole/PTE) <br /> Active Q Passenge! Q Generator 0 Outdoor <br /> Latitude � � D Q Closed 0 Ailered <br /> GPS . I Q Hauler O indoor <br /> L - - -( Q Inactive 0 Truck <br /> Longitude <br /> I End-Use Container <br /> - - _ i Q Planned 0 OTR Q <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 1 A} f 1 t( r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> HAULING AND MANIFEST REQUIREMENTS <br /> V A Q Notice Of Violation Q Extension <br /> Q 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 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 /> Q O Other: § - -- <br /> Comments r 1� � / �p n;� ( 11 ( f _ <br /> ti 31 L. `fly% a 1Ji i '' i-)� 4 ��tV <br /> ('Ab'l�4:, to f� IA (.on(c f , --- <br /> ti <br /> Inspection Form Included: J <br /> uom:nents Included: (1, <br /> Business Rep's Signature Phone Number Inshec+.rd s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACKrrect:® Incorrect: X <br /> White C.py 11/µMB Yellow Copy:Operator Pink Co lt�� <br />