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■ ;: Waste Tire S & Inspection Repor Inspection Report Number ■ <br /> 'u375. State of California <br /> SS®53ri CIWMB 181(New 04/04) Survey Form - Page 1 l <br /> _ 4 <br /> California Integrated Waste Management Board .. . __ ? <br /> Part A- SUrvel BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: <br /> / / Q Routine Q Re inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical-'Address _..- \`✓ z ✓ ��t — - --� =� y - �. ? I 1 i <br /> a <br /> / Inspection Date <br /> Street E <br /> 112 <br /> City State Z/P pode Time In Time Out <br /> Business Rep Title E O AM O AM <br /> O PM 0 '. <br /> Operational Status Tire Type Business Role Storage Type <br /> r i (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> Tire Count (16o"Ie/PTL) a <br /> 4 Q Active Q Passenger 0 Generator Q Outdoor <br /> ^ O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> . Et­,­ <br /> BUSillleSS"rype <br /> (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 a \s , %�_t 1 <br /> Part B - Inspection of Waste Tire Dealer, Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 0 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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> 0 0 Other: § - <br /> Comment J <br /> L <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X _ A i A „�,r� �-I� 1 2 13 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />