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' ` as <br /> ectlon Report �prnber <br /> ste Tire Sur%. & Inspection Report <br /> 'seiliSi State of California <br /> CIWMB 181(New 04/04) �' Survey Form - Page 1 1 d 3 7 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK"INK PEN <br /> Business Profile Inspection Details <br /> TPID- � Q � Q � _ / Inspection Type (Fill one) 11 <br /> Site Suffix: Q Routine Q Re-inspection Q,Referral Q Observation <br /> Local If Referral,choose referral type(Fill,c ne) <br /> Identifier: 7 _J �{�j Q-CHP Q CIWMB Q C�mplaint Q Educational Visit Q Other <br /> Busihess or Facility Name c� - <br /> .� Inspected By � Inspector <br /> IPhysical Address- <br /> tj <br /> Street. <br /> Inspection Date / <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> � r r r m • m 0 PM m 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ❑f Q�f I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 9 Passenger ® Generator Outdoor <br /> + O Q Closed Q;Altered <br /> GPS Latitude m • Hauler Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair . Q 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 I I <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS _ Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> .......--- _ ...-...- ---.. ....... <br /> Q Q —--- <br /> 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers p Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § <br /> ,Comments <br /> Ile— r r�• �J, <br /> 4- <br /> Inspection Form Included: Q'. <br /> Comments Included: Q kt a i - -' <br /> Business -s Signature PhoneInspector's ns ector's Signature Phone Number g <br /> J 1 r 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: t ) : . �Jt. P 1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />