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Waste Tire Sur* & Inspection Report .ispection Report Number <br /> State MWM CIWMB <br /> 181(New <br /> Survey Form - Page 1 4 Z 0 3 2 <br /> +� CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix': 'I 44 I 14 C 7. ;, 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local . If Referral,choose referral type(Fill one) <br /> Identifier. 0 CHP OCIWMB OComplaint <br /> OEducational Visit OOther <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address I �I �I I j I • I I�. <br /> J <br /> Inspection Date <br /> State ZIP Code Time In Time Out <br /> Business Rep Title � I I OI AM 0 AM <br /> PM I ' ( I 0 PM <br /> Operational StatuJ�Fill <br /> re Type Business Role4ontainer <br /> ge Type <br /> (Fill one only) all that app (Fill all that apply) ll that apply) <br /> Tire Count (Whole/PTE <br /> O Active Passenger 0 Generatorutdoor <br /> GPS Latitude ® Closed Altered <br /> o� 0 Haulerdoor <br /> 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR O End Use <br /> • I <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <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 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 O Referred/CIWMB Enforcement <br /> 0 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 <br /> 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> n � <br /> Inspection Form Included: 0' <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Numb <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X I A 11 P I L I L 1112131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />