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ns ection Report Number <br /> R - Waste Tire Sury & Inspection Report _ p -p � <br /> ■ L++�3A State of California " -�} 1 ... <br /> t <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I � <br /> - I a � =� <br /> California Integrated Waste Management Board <br /> Part A Survey BLUE OR BLACK INK PEN <br /> �U9�r1eS8 i r air t rr" r " u � r ssvoioo Detaii <br /> l ti <br /> Litk r1a rLn �._� . <br /> TPID- - TJ Inspection Type (Fill one) <br /> Site Suffix: F( j� f I-' Q Routine Q Re-inspection Q Referral Q Observation <br /> Local ,/ If Referral,choose referral type(Fill one) <br /> Identifier: 1 + / i J ( ij. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> In <br /> Name Fa <br /> Business or—Facility Na11 r <br /> t.,.' Inspected By Inspector <br /> !. ( �C' I r a/_J <br /> _ _ _ J <br /> Physical 'Address <br /> Vf/ <br /> --�-}�--- _. ..__ � 111 ) _ <br /> Street r l <br /> J Inspection Date Fi Ld 11 <br /> f: .'' <br /> city utate ' ZIP Code Time Time Out <br /> Business Rep Title O AM m O AM <br /> y I <br /> = E1 <br /> __—I PM _J__� PM <br /> Operational Status�Fype Business Role tinge.: 13e ` <br /> 6 (Fill one only) (Fill all tha#apply) (Fill all that apply) (Fill all flat apply) <br /> : 1 <br /> �J ®Active Q Passenger; Q Generator Outdoor <br /> C Q Closed (',.'Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive .Truck ' <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> Bust STi e�Deale I allfh Auto Trucking Fleet Government Retreader Q Dismantler Q Tire Derived Fuel 1 <br /> Q New Q p Q 9 Q Q <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 /> Q Q PRCHAULING AN`D MANIFEST aste IREQUIREMENTS <br /> ion oTransport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 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 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0-1-n- <br /> Compliance - No Violations <br /> 0 Q Other: § --- - - -- <br /> Comments <br /> - ( t <br /> 'inspection Form Included. Qt °~ " <br /> I JJ <br /> Comments Included: Q' <br /> Business Reps Signature Phone Number tnspep�tars Signature; Phone Number <br /> r 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: �/ —i r�' <br /> y:� White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />