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fns ection Report Number <br /> ,. Waste Tire Sur�y & Inspection Report _pf'�p <br /> Ct1WMate 181(New Survey Form - Page 1 �t � - iJ i Y V ` <br /> CIWMB 181(New 04/04) ,, <br /> California Integrated Waste Management Board - - ----- - --- .-.. <br /> Part A BLUE OR BLACK INK PEN <br /> "'g-O&P @,+ ,r ar <br /> TPID- _ ",l Inspection Type (Fill one) <br />} Site Suffix: E <br /> �!% jx�, ( Q Routine Q Re-inspection O Referral O Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �)C( l"s {! t' f !{/' + 't / ` O CHP O CIWMB Q Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address A <br /> Street p <br /> Ins ection Date <br /> A � �•� <br /> City State ZIP Code � Time In _ Time Out _ <br /> Business Rep Title O PM 0 AM <br /> 0 AM <br /> M : E <br /> O PM <br /> Operational Status Tire Typesxi h Business Role Storage Type <br /> (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill allthat apply)1 <br /> Tire Count(Whlole/PTE) <br /> O Active 0 Passenger 0 Generator O Outdoor <br /> ® Closed ,:Altered <br /> Latitude <br /> GPS paC(r� (,"�(�ui,✓�%)tr 0 Hauler 0 Indoor <br /> D Q Inactive p'li tick <br /> Longitude — O Planned ') 0 End-Use 0 Container <br /> O New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel li <br /> O Used Tire Dealer Q Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> li O Service Station O Hauler O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V l A HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O <br /> 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m / m / m <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> I <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments ,{. t✓�,( t , fr f ,.�/ L;rlu <br /> J <br /> } <br /> Inspection Form Included: <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: ;_ , , , l_ W L ` 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA �� <br />