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ins ection Re ort Number <br />Ge Waste Tire Sy &Inspection Repo p p <br />ffffff State of California - <br />iff <br />CIWMB 181 (New 04/04) Survey Form <br />Board <br />-Page 1 <br />Q <br />Q <br />California Integrated Waste Management <br />Part A - Survey <br />Q <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />Q <br />TPID -f <br />Site Suffix:E <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Q <br />Q <br />U <br />{{ <br />1 <br />Q <br />Inspection Type (Fill one) <br />(0 Routine Q Re -inspection <br />Q Referral Q Observation <br />Local <br />Identifier: <br />CQy� 7C)A t t.l 1.1 Co on V 2 <br />Q <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name 4 <br />Inspected By <br />Inspector - <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers of Waste Tire Generators <br />V <br />Luc <br />Physical Address <br />F� S1 do o,", <br />Inspection Date <br />Street <br />I `) *C� CA 952©A <br />City State/P� <br />Business Rep Title <br />Time In <br />0 AM <br />Time Out <br />O AM <br />m•MOPM <br />m' 0 P <br />I loc± ew Q\ abL-eI I <br />. -- --- - -- <br />Operational Status <br />(Fill one only) <br />Tire Type <br />(Fill all that apply) <br />-------..- - <br />Business Role <br />(Fill all that apply) <br />Storage Type <br />(Fill all that apply) <br />Tire Count (Whole/PTE) I <br />�I� <br />I <br />I. <br />{ <br />I <br />I <br />I <br />1 f <br />Q Active <br />Q: Passenger <br />Q Generator <br />Q Outdoor <br />GPS Latitude <br />m <br />• <br />O <br />(D Closed <br />Q Altered <br />Q Hauler <br />Q Indoor <br />O <br />Q Inactive <br />Q Truck <br />A <br />Longitude — <br />Q Planned <br />Q OTR NIA'Q <br />End-Us�e�� <br />Q Contain <br />Business Type (Fill all that apply) I <br />j 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />0 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 <br />V <br />_ A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of.Manifest Forms and Tire Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers of Waste Tire Generators <br />n <br />n <br />Other: § , <br />Comments <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred/ CIWMB Enforcement <br />Q In Compliance - No Violations <br />CSP 1 C� l5 3 X25 <br />UFA 7T_ , <br />nspection Form Included: OX <br />Comments Included - — ._ _ __.._ _ _.....------ -- <br />- --... .... - <br />Business Rep's Signature Phone Number Insp 's Signature Phone Number <br />62081 <br />INSTRUCTIONS ON BACK Correct: Incorrect: Vj k= -.. AIPILIE1 1112.13 <br />0 White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA ® ■ <br />