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Vection Report Number <br /> Waste Tire Sue-6y & Inspection Report' _ _ <br /> State of California 1 f �" I <br /> CIWMB 181(New 04/04) Survey Form - Page 1 0 10 .A 1 J_.5 5.0_.-.1 <br /> California Integrated Waste Management Board _ - <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey i <br /> Business Profile -" pvebkgI� ' <br /> TPID- „ }} Inspection Type (Fill one) <br /> Site Suffix: 1 1 a Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 1-� If Referral,choose referral type(Fill one) <br /> Identifier: Ei0(tet;ti 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> ; i <br /> I <br /> "Physic.1dress � 1 <br /> Street l �� <br /> Inspection Date D-51 <br /> Time In Time Out <br /> City State ZIP Cade __ ,Business Rep Title O AM EO AM <br /> [j­­ <br /> ___� O PM LJ ' O <br /> � All <br /> �j n PM <br /> tYr t; a J F� 1 t p Type <br /> PP Y) <br /> Operation Status Tire T e Business Role Storage Type <br /> ,M`(Fill one only) (Fill all that a I ! (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) = <br /> 4r Active D Passenger 0 Generator 0 Outdoor <br /> _ D 0 Closed 0 Altered <br /> GPS Latitude -� 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude 0 Planned 0 OTR End-Use 0 Container <br /> 9 7 1 n. " 9 <br /> j <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair Q Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> O I <br /> 0 UsedT' e Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other <br /> Part B -'Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A i 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 /> O O 14 CCR§ 18459 _Responsibleonsible Entities Complying <br /> ingwith <br /> Manifesting Requirements uirements Date n <br /> m m I <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 9 Y 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 I CIWMB Enforcement <br /> 0 1 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § ---- -- -.-_.-- - <br /> Comments - 1 i 1 �� t <br /> i -� �-' ) t�;r .�f f� ��L <br /> �I VIA , I��% ?» r Vt i I , l u V - - — <br /> - <br /> Inspection Form.Included: 0 <br /> Comments Included: 0Ins Inspector's Signature y Phone Number <br /> Business Rep's Signature Phone Number p g _ <br /> o 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �/ ��'�, ` <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © S <br />