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T ■ <br /> Waste Tire C - 'Inspection Report Number <br /> y & Inspection Report T 1 <br /> ■ A <br /> State of California <br /> i _ page 1 y i 1140760 <br /> CIWMB 181(New 04/04) Survey Form <br /> californialntegratedWasteManagementBoard BLUE OR-BLACK INK-PEN_ <br /> — — _ <br /> Part A. Survey - _ Inspection Details - <br /> Business <br /> -- - —Pro-file- <br /> - --- � - -- Inspection <br /> nspection-Type <br /> Fill one <br /> Q Referral Observation <br /> Site Suffix: � Routine Q Re-inspection <br /> -- If Referral,choose referral type(Fill one) <br /> Local Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Identifier: scW► �tf <br /> Busess or Facility Name Inspected By Inspector <br /> in <br /> PhysicalAd-dress - <br /> i <br /> Inspection Date 1 <br /> tAa,vk G ' Time In i AM Time Out 0 AM <br /> ® <br /> Business Rep Title 1 I © 0 PM * PM <br /> Operational <br /> one only)I Status <br /> LLAa,y-U cvf l6k _ _ p Tire Type Business Role Storage Type <br /> - ---- -------— ( y) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) © ® Active ® Passenger ® Generator Outdoor <br /> - —- - - — Q Closed Q Altered Q Indoor <br /> Q Hauler <br /> Latitude Q Truck <br /> GPS Q Inactive <br /> � Q End-Use Q Container <br /> Longitude - Q Planned Q OTR <br /> Business Type (Fill all that apply) Q Dismantler <br /> Q New Tire Dealer ®Auto Repair Q Tire Derived Fuel <br /> Q Trucking Fleet Q Government Q Retreader <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection <br /> Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture <br /> Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> ! A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Extension <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 I Q PRC§42956-Registration/Decal in Vehicle m <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q Q Referred/CIWMB Enforcement <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <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 0 In Compliance No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: Q'i <br /> Comments Included: ® Bu in ss Rep's Signature Phone Number - nspector's Signature Phone Number <br /> - - -- 62081 <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect A ; V1 A ' r 1i <br /> White Copy:CIWMB Yellow Copy:Operator Pink C EA <br />