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Waste Tire Shy & Inspection Repor nspection Repot Number <br /> , <br /> State B California <br /> °a Survey Form - Page 1 li tVj tVj jVy {1 <br /> p CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board -._ <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details LL Y4 y LL y„ <br /> TPID- 1 Inspection Type (Fill one) <br /> Site Suffix: .f�t/ x� % - �I f 0 Routine 0 Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: z, 7 10 CHP O CIWMB O Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> Physical Address <br /> Street <br /> / Inspection Date <br /> City State ZIP Code) Time In Time Out_ <br /> Business Rep Title O AM Q AM <br /> O PM Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> The Count (Whole/PTE) (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply). <br /> ' Q Active O Passenger Q Generator O Outdoor <br /> O ® Closed 0Altered <br /> GPS Latitude _ _T Hauler Indoor <br /> O 0 Inactive 0 Tlaar.,k <br /> Longitude - I . Q Planned 0 OTR 0 End-Use 0 Container <br /> II <br /> business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 0 Dismantler Q Tire Derived Fuel <br /> 0 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 /> - <br /> - <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - 0 Notice Of Violation 0 Extension <br /> O 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / 71 / 111 <br /> 0 Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 Q 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 Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> - .f� f / � .1 _ --�- - - -'- ,�fG f' iJ v' /'�i:'J /•�` "�.t'.i':.'J[r,,. _ .=t ,�., r_� ! .' _ <br /> f , <br /> Inspection Form Included: 0 <br /> Comments Included: D <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X � 1 A MI P j3�! i ilia� <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />