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Waste Tire Su y & Inspection Reportaspection Report Number <br /> WHO State of California - h <br /> CIWMB181(New 04/04) Survey Form - Page 1 {`•,�7 <br /> California Integrated Waste Management Board <br /> Part_A- Survey__ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: � "'' -. ' <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Localp �` - If Referral,choose referral type(Fill one) <br /> Identifier: 5 CL" "Sc, l�ovtM. `J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ` \ �^(prv�� GI �C! r�` <br /> Inspection Date GI <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> 1 '5 ®PM J 7 Is PM <br /> (Z v�C"' `��w C) S ti c VVI -- <br /> -- --- - - -- - --- - Operational Status Tire Type Business Role Storage Type <br /> The Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) � (Fill all that a <br /> pply) <br /> ® Outdoor Active Passenger Generator <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive �Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V r A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q 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 Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days �' <br /> (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years I <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers tt O 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 /> O O Other: § -- ---- - <br /> i <br /> Comments �L5 �c>�'.i1�L� itn u;iW•t'�-L� ���.� � � yt„U I -� <br /> c <br /> --- <br /> �, - , � � ►-c��- Cl�,t,� n�� �( a� (, w�s1� 1 — l ,rte, <br /> ,inspection Form Included: Q �0 <br /> Comments Included: 0 �)U4 <br /> - - <br /> Business Rep's Signature--Phone Number In ector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct ® Incorrect' ( >( f 1 I XI A'Mj P j L(E y I I I 62081 <br /> White Copy:CIWMB _ Yellow Copy:Operator Pink Copy:LEA <br /> r <br />