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Waste Tire-Sft & Inspection Repo' Spection Report Number <br /> � ® State of California + - <br /> CIWMB181(New 04/04) Survey Form - Page 1 ! +111 -_ <br /> California Integrated Waste Management Board _ <br /> Part A- Survev To sq-BBLUE OR BLACK INK PEN <br /> a. =.)rte .✓ . <br /> } So <br /> TPID- Inspection Type (Fill one) f <br /> Site Suffix: – - <br /> - - Q Routine Q Re-inspection .Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> _ QCHP QCIWMB QCom Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name - <br /> - Inspected By Inspector <br /> Physical Address <br /> Street <br /> +� Inspection Date <br /> �t <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title <br /> LIJ . 1OAM 0 A <br /> ° <br /> - ;0 PM O PM <br /> u ,.. O erational Status Tire <br /> p Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fillall that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> El <br /> O Q Inactive Q Truck <br /> Longitude .I <br /> Q Planned � )"(`iR�'� ' Q End-Use Q container <br /> LIS <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 /> 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 m m / m <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 i 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 <br /> Q In Compliance - No Violations <br /> Q 10 Other: § <br /> Comments <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:* Incorrect: XAk E 62081 <br /> ""° l d I l l i <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br />