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-w Ism <br /> Waste Tire Sety & Inspection Rep .Inspection Report Number <br /> -if11. State of California A <br /> CIWMB181(New 04/04) Survey Form - Page 1 $ - 10 1 4. 7 6 51 <br /> California Integrated Waste Management Board <br /> Part A- SurveV BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: , 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ��� If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Street <br /> _ Inspection Date / <br /> City 1 State ZIP Code Time In Time Out <br /> Business Rep Title m Q AM O AM <br /> m L�L�_ 0 PM 0 PM <br /> Operational Status ire Type Business Role Storage Type <br /> Tire Count (Whole/PTE (Fill one only) J all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Passenger 0 Generator 0 Outdoor <br /> I� O 0 Closed Altered <br /> Latitude W <br /> GPS � Hauler � Indoor <br /> O 0 Inactive '0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ®Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 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 0 Referred/CIWMB Enforcement <br /> 0 0 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 /> 0 0 Other. § <br /> Comments <br /> Inspe ton Form Include ^ <br /> Comments Included: 0 - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Numbe <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X E XjAjM P JL E1 11 L - <br /> White Copy:CIWMB Yellow Copy Operator y Pink Copy:LEA <br />