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Waste Tire Sui. y & Mspectoon ReportInspection Report Number <br /> co ' tate of California �1I I � - � <br /> CIWMB 181(New 04/04) Survey <br /> B�'ve Form ® Page -ry ', 1 <br /> California Integrated Waste Management Board x&,,4411 u @H Form d H 6 61 i <br /> Part A- Surv� --- BLUE OR BLACK_IN_ K PEN <br /> ;-Bu <br /> - - — — - _ <br /> siness Profile Inspection Details <br /> action <br /> Ins LD p Type (Fill one) — - - - <br /> Site Suffix: f <br /> TPID- <br /> Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local - If Referral,choose referral type(Fill one) <br /> Identifier: <br /> (�.r`r 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility <br /> - Inspected By Inspector <br /> -1 <br /> Physical Address <br /> Street <br /> Inspection Date <br /> City State ZIP Code j I Time In Time Out <br /> Business Rep < Title II AM I1 I mOAM <br /> PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> -� <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> �-pude I j 0 Closed 0 Altered <br /> j - I I ° l 0 Hauler 0 Indoor <br /> --- 0 Inactive 0 Truck <br /> Longitude i 0 - - O - 0 End-Use 0 Container <br /> Business Type (Fill all that apply) Planned OTR <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 Q 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 EN_FO_RCE_MENT STA_ T_US <br /> PRC 42951 -Waste Tire Hauler Re istration and Trans ort of Tires <br /> V A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation <br /> 0 0 T— § g p 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date 11:11111:11 <br /> 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 li 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 /> 1 - ! <br /> Inspection Form Included: 0, <br /> Comments Included: 0;.. <br /> Business Rep's;Signature - Phone Number Inspector's_ Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect ( � ,�/�� �'��, �w7; E <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />