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Waste Tire SA0q,4 Inspection Repo �pection Repor�a tuber. <br /> ciic4 ■ <br /> iwState of California <br /> CIWMB 181(New 04/04) Surveyform - Page 1 1 , 4 - 1 0 2 5. � $ <br /> California Integrated Waste Management Board a <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I <br /> nspection a Inspection Type (Fill one) <br /> Site Suffix: -7 7- (E),Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local .1 If Referral,choose referral type(Fill one) <br /> Identifier: ` <br /> Sc��� Jt?-. �.. �,-. ���.•..•'-►"' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business <br /> or Facility Name Inspected By Inspector <br /> Physical Address / c-) ' �L it rr __�c F�� 5 <br /> A -- <br /> Street <br /> C5Inspection Date O <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0PM m ' m 0PM <br /> Operational Status Tire Type Business Role Storage Type f <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I� 0Active 0 Passenger 0 Generator 0Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude m • 0 Hauler 0, Indoor <br /> O 0 Inactive :Truck <br /> Longitude — 0.Planned 0 OTR 0 End-Use 0,Container <br /> Business 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 I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V , HAULING AND MANIFEST REQUIREMENTS <br /> , A <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 / m / 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 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/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18,462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q In Compliance - No Violations <br /> 0 0 1 Other: § q —, <br /> Comments— C—)S , t Ara <br /> 2C5 55 5 62 m _ <br /> Inspection Form Included: f <br /> 1 <br /> Comments Included:01 ---" - -- .... <br /> Business Rep's Signature Phone Number/ Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ( �/ .A M P e 1 2 <br /> • ��,, � �� 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® r S <br />