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■ - —n--s-- ec_t--_i-o_--n Report N <br /> u--mberWaste Tire Sy & Inspection Repor I <br /> State of California 3 CIWiMB 181(New 04/04) <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part <br /> --- <br /> A- Survey BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> � TPID- Inspection Type (Fill one) <br /> � J � Lcul <br /> Site Suffix: (@0Routine Q Re-inspection Referral 0 Observation <br /> Local / 1 If Referral,choose referral type(Fill one) <br /> Identifier. .('z j� (�C✓ f 't( � _ 0 CHP Q CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name I <br /> / Inspected By Inspector <br /> XMGM <br /> Physical Address _/ I <br /> I _,,1 <br /> Street n <br /> - Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep TitleF Q AM Q AM <br /> Ljj? <br /> ` ✓ <br /> Q PM QPM <br /> ,a � � <br /> Operational Status Business Role Storage Type <br /> 'r; �I T a" <br /> (Fill one only) {6( IM% � �q (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> ('Active 1 Q Generator 0 Outdoor <br /> O O Closed <br /> ,irz'w <br /> GPS Latitude Q Hauler 0 Indoor <br /> Q Inactive <br /> 0 End-Use 0 Container <br /> Longitude — ]O O Planned <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government 0 Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> 0 Service Station 0 HaulerQ Agriculture Q Shredder (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 Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / M <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> 0 O Other: § <br /> Comments 1 ' I <br /> S4r l �I✓t�tC it �'� rf k, r,20l( ' <br /> (a A ( r6c �1� 1 � �0 .l�r-1 0J L t:t f.(-f A-"A �( = ( h) V I�V11 via,a i't II / �vr i , i <br /> f', 7 <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 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />