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spection Waste Tire Su*y & Inspection ReportReportvNum/�ber <br /> ■ ." State of California I 1 — 1 ® 8 8 J 4 L <br /> CIWMB181(New 04/04) Survey Form - Page 1 - <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> —1 <br /> Business Profile Inspection Retails <br /> �s rs -- - <br /> { Inspection Type (Fill one) <br /> Ste Suffix: `-�� Routine Q Re inspection Q Referral Q Observation <br /> Local l /' l - If Referral,choose referral type(Fill one) <br /> CIWMB Q Complaint Q Educational Visit Q Other <br /> Identifier: l� �' Q CHP Q <br /> Business or Facility Name Inspected By Inspector <br /> Ln V1 <br /> Physical Address <br /> I.� <br /> Street <br /> Inspection Date <br /> (! L_ <br /> -T y <br /> I <br /> State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> Title <br /> 0 PM F-ST� 0 PM <br /> ,Operational Status Tire Type Business Role Stor tl Type '{ <br /> F (Fill one only) (Fill all th1 .11at apply):• (Fill all that apply) `(Fill all that apply} <br /> Tire Count(Whole/PTE) ,t ® <br /> ctive Q Passenger Generator Q Outdoor <br /> AQ <br /> - -- Q Hauler <br /> Latitude-- - j -- ,0 Q Closed Q Altered <br /> �pS I ( � � � Q Indoor <br /> �_._. 0 InactiveQ Truck <br /> � •� 0 <br /> - ' <br /> �� Q End-Use Q Container <br /> Longitude - s I Q Planned Q OTR <br /> Business Type. (Fill all that apply) <br /> Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet <br /> Q Used Tire Dealer Q Auto Body g 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 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 RequirementsDate m <br /> Q 1 Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 C CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities --- -- -- --- <br /> Q ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 to Compliance - No Violations <br /> Q Q (Other: -- <br /> Comments <br /> G Irlt f i _ j 1Qii T _ r <br /> f <br /> ,inspection Form included: Q <br /> y N <br /> B Hess Reps Slgnatu <br /> Comments Included � � re Phone Number Inspector' _$gnatu►e a �d# <br /> —. <br /> --- ___ 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X l i <br /> White Copy:CIWMB Yellow Copy:operator Pink Copy:LEA <br /> 0 <br />