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Waste Tire Suf &~' Spectlon Repor pection Report Number <br /> State of MB181ifornia Survey Form - Page 1 J 2 <br /> CIWMB 181(New 04/041 <br /> California Integrated Waste Management Board - -- - <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> �tl#, gpQtWbtt,El �l� a ��n '� <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: <br /> 11! I �/ I I� Q Routine to Re-inspection Q Referral Q Observation I <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By _...__._. Inspector H7 <br /> Physl <br /> Street <br /> Inspection Date <br /> Time In Time Out <br /> City - State ZIP Code __ , , <br /> Business Rep Title r O AM O AM <br /> O PIVD : E <br /> 0 PM <br /> OWN= Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply) <br /> Pr Q'Active 0 Passenger 0 Generator 0 Outdoor <br /> ANN <br /> t0 0 Closed 0 Altered <br /> Lati!ude=-='� <br /> GPS 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — ePlanned OTR 0 End-Use 0 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 /> I � <br /> 0 0 Other: § <br /> Comments <br /> ._ t: - ,.;! .... >,.-. '1"f � ? �� � ,,,�: I�G ��.� {` .art-^M-G• �t _!� <br /> .fes~ <br /> Inspection Form Included: 0' <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X V r <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA 6Uz" <br />