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r�rx <br /> Waste Tire Sufty & Inspection Reporinspection Report Number <br /> IS <br /> X <br /> : State of California <br /> CIWMB 181 <br /> (New 04104) <br /> California Integrated Board Survey Form - Page 1 ) - 10 13 <br /> L { <br /> 5 <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> spection Details <br /> TPID- ( I I I Inspection Type (Fill one) <br /> Site Suffix: ! J / 1 II 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> _ I <br /> Business or Facility Name ` Inspected By Inspector <br /> Physical Address 1 ( I I I J <br /> Oki r ex <br /> Street Inspection Date 1 / <br /> Oki L j = <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> ` / O PM I ' O PM <br /> I � �rf `iVJE / J, I <br /> I <br /> R �V� � I to ,,,� ,� �� ti�,„,,, , „,� Operational Status Tire Type Business Role Storage Type <br /> Tire Caunt Whale/PTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> .. ® Active enger 0 Generator 0 Outdoor <br /> GPS Latitude I . I I �J 0 ClosedJL' <br /> ed0 0Hauler Indoor <br /> 0Inactive k <br /> Longitude - 0 Planned 0 End-Use 0 Container <br /> 0 New Tire Dealer (b 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 /> — - - - 0 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 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 0 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 0 In Compliance - No Violations <br /> i <br /> 0 0 Other: § <br /> I <br />.. Comments f <br /> �•:.V LA r"A %ft <br /> Pii rQi'i'r, (^ 1()�( ( i±7 G� {:tC� lO' � I ( lrty Lt Ll ;j(-y�L1t �•;� ! _. <br /> .I t r C Lt< <y�� �1 �r 'r (A ,.I ,�(l kC(r� t�Prt;r�� ��. ;:c�t` <br /> �/`x t( <br /> ( w;� � <br /> Inspection Form Included: <br /> Signature Phone Number ,. Ins ector S,"S' r <br /> -Included: 0 <br /> Business Rep's g p yature Phone Number <br /> Comments <br /> 62081 <br /> INSTRUCTIONS ON BACK CorrectV Incorrect: X P I L I EI j 1 <br /> k White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> t� <br />