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�. Waste Tire Suy & Inspection Repornspectlon Report Number <br /> State of California <br /> - - - - - ■ <br /> Survey Form - Page 1 <br /> CIWMB 181(New 04/04) �_ �___ � ._� �_.� �_ � � I <br /> California Integrated Waste Management Board , <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> } TPID- Inspection Type (Fill one) <br /> Site Suffix: Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP QCIWMB QCom Complaint Q Educational Visit Q Other <br /> Business or Facility Name - - <br /> Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title <br /> 0 PM ET-1 : <br /> ET] 0 PM <br /> I� j � I I 1 P �atl—.� I • - <br /> p,iii;ii iffliliffig 1: :1tional StatusOeri Business �i <br /> Role <br /> Ml mrVIR 71 <br /> The Count(Whole/Pl (Fill one only) )L,a` (Fill all that apply) <br /> -E) <br /> Active T Y Q Generator �� <br /> Latitude m O Q Closed <br /> GPS L—Li __ VQ Hauler F € <br /> Q Inactive <br /> ffik <br /> Longitude - O0 Planned ;f Q End-Use ,' <br /> Business Type (Fill all tha <br /> ���� 5i � �ix,aXr � ,`u,�)>> ilk ;. �f. ,u, m"�.. ,��` <'��"���"Pw�i ,.���`•:,'�n� � a�'��.",�.,.,4.�!t. ��w' ����. k.'��Ii�,,r ,.a". �*$i''��. ,.a"" ^�.. �9�% <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 / Ell <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 /> 1 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 <br /> QQ 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Other: § Q In Compliance - No Violations <br /> Comments ._ r <br /> Inspection Form Included: Q - — <br /> Comments Included: Q _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> " .. 62081 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X Ak \/ E. X i A I��r a, � , <br /> ■ _ © s <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />