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_ Waste Tire Sury - & In 'i ction Report Inspection /R''�ep//''ort Number <br /> » - State of California 7 U V �+ <br /> CIWMB 181(New 04104) Survey For - age 1 I - V V <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> 'art A- Survey _ - <br /> iusiness Profile In ection Details <br /> TPID- ) In ection Type (Fill one) <br /> Site Suffix: 1 8 D ! A outine Q Re-inspection Q Referral 0 Observation <br /> Local eferral,choose referral type(Fill one) <br /> Identifier: Q CHP O CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> �t Inspection Date D 5 <br /> Time In Time Out <br /> QAM / 0 A <br /> Business Rep Title O PM D (� PM <br /> CA\\ems`��vnd-elras �— w <br /> Operational StW <br /> Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) , <br /> Active ® Generator or <br /> Closed <br /> GPS Latitude Q Hauler Q Indoor <br /> 41 Inca ive ruc <br /> Longitude - J°nned Q OTR <br /> O End-Use O Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair ® Trucking Fleet Q Government Q Retreader\- Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other - - <br /> -ENFO Violation Extension <br /> Part B - Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ' ENFORCEMENT STATUS_ <br /> -- -------------------------- -- <br /> V A HAULING AND MANIFEST_REQUIREMENTS ;0 Notic O <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 <br /> Q 0 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 EXE <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 I CIWMB Enforcement <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> -- <br /> 0 O Other: § -- - -- -- <br /> Comments t_ <br /> vs— <br /> i� <br /> LZ <br /> Inspection Form Included: L <br /> p O o j X33 '10 _ `153 ��$ <br /> Comments Included: QIns ure Phone Number <br /> Business Rep's Signature Phone Number p_ -. - --- <br /> - ---- - . 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect <br /> White Cc.-,,-CIWMB Yellow Copy:Operator Pink Copy:LEA <br />