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Waste Tire SAy & Inspection Repor +nspection Report Number ■ <br /> ■ •,, State of California "� - a <br /> CIWMB 181(New 04/04) Survey Form - Page 1 = -_ <br /> California Integrated Waste Management Board E <br /> Part A- Survv y _ BLUE OR BLACK INK PEN 1 <br /> - - speGtl�h petalls <br /> _ ' <br /> T�PID- i r I - I Inspection Type (Fill one) <br /> Ll 1Q Routine QRe-inspection QReferral QObservationSite Suffix: <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: - ; Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical"Address <br /> Street <br /> -• Inspection Date <br /> State Z/P Code I Time In Time Out <br /> Business Rep TitleAM O AM <br /> a ED0PM � �,M_ _ QPM <br /> - Operational Status rreTpe, Business Role arge �tpe <br /> (Fill one only) (lfrl all thdt apply (Fill all that apply) (Fill ail that apply) <br /> Q Active �� " `�"" 1 Q Generator Q butdpor <br /> D Q Closed <br /> GPS Latitude � �� ,'; Q Hauler Q Indoor, <br /> D Q Inactive Q <br /> Longitude - Q Planned Q Q End Use Q Container <br /> Business <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 Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q <br /> 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance No Violations <br /> Q Q Other: § - - --- - <br /> Comments <br /> ' f <br /> In P x•Qa�a WI <br /> ��� r <br /> g' <br /> f <br /> Comments Included Q,Busi <br /> nessRep's Signature Phone Number T Iw <br /> — - • 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: : � � A <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />