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` Y & Report <br /> Inspection Report NumberIns <br /> Inspection Waste TireSuI <br /> State Californi <br /> --: 9M CIWMI 181(New Survey Form - Page 1 1 � �1 Q 2 5 � Q �� <br /> n�q� CIWMB 181(New 04/04) <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: ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �,, �� E: N 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street _ - I _ <br /> c " Inspection Date.14 <br /> I Cl 17 n <br /> Ltv State ZIP Code Time In Time Out <br /> Business Rep Title I O AM O AM <br /> O PM - O PM <br /> Operational Status Tire Type Business Role 'Storage Typ <br /> ire'Count(WholelPTE)'j 1 ®one only) (Fill all that apply) <br /> t (Fill all that apply) (Fill all that ap <br /> ( y) ( pp y) <br /> Active Passenger ! �°Generator 00 utdoor <br /> Latitude I . I I" 0 Closed 0 Altered <br /> GPS 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> U <br /> ; <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Containerµ <br /> Business Type (Fill all th 0 "'' <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet ® 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 --- I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ; A I 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 /> 0 0 Other: § <br /> Comments � �_��,� <br /> r, G-' �._ <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> I - - -- 62081 - <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X A. aYl IPME1 1112131 <br /> While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />