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`��`N■ Inspection Report Number Tire S *ey & Inspection Repore <br /> nS .n State California <br /> CIWMBB 181(New 04/04) Survey Form - Page 1 I <br /> Cahforma Integrated Waste Management Board _ - , <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile; <br /> } TPID- (< - Inspection Type (Fill one) <br /> Site Suffix: i li I �J� 74 (..� ® Routine QRe-ins Re-inspection <br /> Q.Referral Q Observation <br /> 'Local `i If Referral,choose referral type(Fill one) <br /> Identifier: QCHP Q CIWMBQ Complaint Q Educational Visit Other <br /> Business or Facility Name t ' <br /> 1� f Inspected B <br /> Inspector <br /> Physical Address <br /> VV I <br /> Street <br /> 1 %4 , d Inspection Date <br /> r : <br /> city ^- State ZIP Code_1 Time In� Time Out <br /> Business Rep Title Q AM <br /> ] 0 AM <br /> 0 P 0 P <br /> M <br /> -- <br /> Operational Status Tire Type r✓' !Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r% Q Active Q Passenger a Generator 0 Outdoor <br /> GPS Latitude m • 0 Q Closed Q Altered <br /> p I Q Hauler Q Indoor <br /> 0 Q Inactive Q T!-ucK, <br /> Longitude - r Q Planned Q OTR Q End-Use Q Container <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 /> - - -- - ---- ----- Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 ! Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline ' <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date [T] <br /> Q Q 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 Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement r4,+ <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 Q Other: <br /> Comments <br /> 1 ��l lit(l � ._ r _ I!1 ^ .�"4 00✓ ,/'((( <br /> Slid <br /> 1 <br /> Inspection Form Included: Q <br /> Comments included: Q <br /> Business Rep's Signature Phone Number inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:is Incorrect: X A ,01, P 1 2 .3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> it <br />