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a <br /> Waste Tire Su, ;y & Inspection Report nspection Report Number <br /> CIWMState B <br /> 181(New <br /> Survey Form - Page 1 I 1 - 1141240 <br /> CIWMB 181(New 04104) Y 9 <br /> California Integrated Waste Management Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> ss ` Inspection Details <br /> 11ta ........... <br /> TPID- ) .- Inspection Type (Fill one) <br /> Site Suffix ! 3 l� loll Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier. <br /> 1�a t1 Q t 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> StiEt'? . <br /> Inspection Date <br /> /' vvv r f I <br /> C A <br /> City State ZIP .ode Time In Time Out <br /> r <br /> Business Re - -- _._._ .._. .. .. <br /> P Title ( ( AM <br /> % 0 PM i . 1��T <br /> 'nn ` i (3 AM <br /> ' f 0 PM <br /> ._ _ _ -- -3t` v2eeQeS�_ <br /> - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ire Count(Whoie/PTE) ` <br /> 10 ®Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude ( 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Bu ness 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 /> 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 /> i0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive 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 /> Comments12u�k' � <br /> �D( �(� I���� c�tt,r�� U1 �� ' / t_ �- � t►�____,�c���i : � <br /> Inspection Form Included: 0 <br /> Comments Included; 0 <br /> Business Rep's Signature Phone Number Inspectof's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X X i A. <br /> X41 P L 62081 <br /> 2 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />