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Report Number <br /> Waste Tire SuSby & inspection Repor Inspection ■ <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 0 4 810 ___ <br /> California Integrated Waste Management Board - - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Ins13 f, <br /> TPID- —� - Inspection Type (Fill one) <br />} Site Suffix: i ii r`"I �� ®Routine Q Re-inspection Q Referral Q Observation <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 /> Phydical Address <br /> Street , Inspection Date O <br /> S-. Time In Time Out <br /> •r State ZIP Code _ _._— <br /> Business Rep Title : O PMAM I _J]. � O AM <br /> PM <br /> Operational Status Tile Type Business Role Storage Type <br /> apply)Y) ( p Fill all that apply):: <br /> rt' w (Fill one only) Gill all that a I Fill all that apply) ( <br /> Tire C.ou�l. 1 hole/PTE) <br /> L Active Q Passenger Q Generator Q Outdoor <br /> PS Latitude O 0 Closed Q Altered <br /> Q Hauler Q Indoor <br /> GW � Q Inactive Q Truck <br /> Longitude - FTTI -FTT77-1 Q Planned Q OTR Q End-Use Q Container <br /> - <br /> Business— - <br /> Type (Fill all that apply) - <br /> - Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government <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 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§ 18459 Responsible Entities Complying with Manifesting Requirements Date <br /> 0 1 Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q (Required for NOV or EXT) <br /> 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> 0 0 Other: § -- - -_ _ _ - <br /> Comments E �• �' t cw_>� <br /> �j t / c <br /> 1 I <br /> Inspection Form Included: Q'; <br /> Comments Included: Q- - <br /> Business Rep's :Signature Phone Number Inspector's Signature._._ Phone Number <br /> _ - 62081 <br /> INSTRUCTIONS ON BACK Correct:I* Incorrect: X , \/ ,, "� l- <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> ■ <br /> i <br />