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Waste Tire Su <br /> ._ ft & Inspection Report nspection Report Number <br /> -------- --r ----.. <br /> ■ �G��CB State of California Y 1— f _ - <br /> CMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board w 1 <br /> Part A SIll BLUE OR BLACK INK PEN <br /> It57 � 7tdrJ).,ysdd`�uew <br /> i y�r'�,��," <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix <br /> 0 Routine � Re-inspection 0 Referral 0 Observation <br /> Local ( If Referral,choose referral type(Fill one) <br /> Identifier: _., ' CHP CIWMB Complaint 0 � 0 p 0 Educational Visit 0 Other <br /> Business or Faculty Name r� !J - Inspected By Inspector <br /> Physical Addfe s <br /> } <br /> Street <br /> Inspection Date <br /> City T State ZIP Code Time In Time Out <br /> Business Rep Title O AMAM <br /> r, i • 0 PM i �7 O PM <br /> _ — <br /> a .�Operational Status Tire Type Business Role Storage Type <br /> I' a (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply):l <br /> Q0 Active 0 Passenger 0 Generator 0 Outdoor' <br /> Latitude C 0 Closed 0 Altered <br /> GPS 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude – 0 End-Use 0 Container <br /> III 0 Planned 0 OTR <br /> R <br /> Business Type (Fill all that apply) <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 <br /> i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS_ <br /> - -- - - <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 / 0 / 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 1 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 I 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 /> Inspection Form Included: 0: <br /> Comments Included: 0 - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: v 62081 <br /> Incorrect: /� F- A M� P <br /> i <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />