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Waste Tire Surby & Inspection Report nspection Report Number <br /> State CJWM 181(California Survey Form - Page 1 i 1 i <br /> CIWMB 181(New 04/04) g <br /> California Integrated Waste Management Board `�•' <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I Q Routine O Re-inspection O Referral Q Observation <br /> Local r 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 Y / Inspected By Inspector <br /> bhysical Address L .1L LI o <br /> i <br /> Street <br /> Inspection Date 2J .::) I 0 / <br /> City state ZIP Code Time In Time Out <br /> Business Rep Title 0I AM 0 AM <br /> PM I ( ' I I QPM <br /> Operational Status ire Type Business Role orage Type <br /> Tire Count (Whole/PTE (Fill one only) Fill all that apply) (Fill all that apply) ill all that apply) <br /> J Q Active Passenge Q Generator Outdoor <br /> IF, 'I 'I ILatitude ® Closed Altered <br /> GPS i I I I I i I O Hauler Indoor <br /> Q Inactive Truck ' <br /> Longitude — Q Planned OTR O End-Use Container <br /> Q New Tire Dealer O Auto Repair Q Trucking Fleet Q Government O Retreader 0 Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> Q Service Station Q 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' i /I► I FijtluI JidliLl 110ANIF ESI" i1El',IIUIFtEMENTS <br /> Notice Of Violation 0 Extension <br /> O ` O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> 0 O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 O Other: § <br /> CommentsTIMMER <br /> 404 <br /> Inspection Form Included: 0 — - <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X XI A 0I F I L I EI It 12131 I3 <br /> 2 <br /> 081 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />