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} Waste Tire Suley & Inspection Report�nspection Report Number <br /> State of California I ;� Ti �9 n <br /> CIWMB 181(New 04/04) Survey Form - Page 1 s E <br /> California Integrated Waste Management Board - �`� '� £ u-1 ' <br /> Part A- Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Pid <br /> ►,IS <br /> , _ Lii <br /> TPID- r �; � f - � Inspection Type (Fill one) <br /> Site Suffix: � I T� � ! � <br /> ®_Routine 0 Re-inspection 0 Referral 0 Observation <br /> -Local - - f If Referral,choose referral type(Fill one) <br /> Identifier: I <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> { ' Inspected By Inspector <br /> l' ✓I ; r <br /> Physical Address Ll_1 <br /> -- <br /> Street <br /> Inspection Date <br /> 7 , <br /> State ZIP Code Time In Time Out <br /> Business Rep Title `` 0 AM 0 AM <br /> O PM� O PMIA r i l III - <br /> _ . <br /> .....-- --- , Operational Status Tire Type Business Role Storage Type <br /> 7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) O <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude (( {` ( 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 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 /> p - - -- <br /> ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Part B- Ins Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> — 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> 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 <br /> M / m / m <br /> 0 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/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 /> 7 <br /> Inspection Form Included: 0'', <br /> Comments Included: 0: <br /> -- <br /> Business Rep's Signature Phone Number Inspector's Signature .; Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X l I_ ; <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® 0 <br />