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x <br /> =;aWaste Tire SO'vey & Inspection Reoo Inspection Report Number <br /> State NOW CIWMB <br /> 181(New <br /> Survey Form - Page 1 i - 1 G 4 7 0 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / -�1l Inspection Type (Fill one) <br /> Site Suffix: 1 l7 L L+ 2 - Q 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CIWMB O Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> P ysical Address - <br /> Inspection Date 0 Z Z C> t <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> Q PM Q PM <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 /> Tire Count (Whole/PTE) <br /> ' f �' O Active Q Passenger Q Generator Q Outdoor <br /> D O Closed Q Altered <br /> GPS LatitudeC. U0 0 Q Hauler Q Indoor <br /> O Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government O Retreader Q Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br /> Q Service Station O Hauler O Agriculture Q Shredder ® Other V <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> ,SND MANI 9STttE4tttREME�NI S}, ., r' .. « _= - .>.; <br /> Awli <br /> *Noti" Of=Violatio <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires «�• r',. <br /> O O 'PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O Q Date m / m / m <br /> I <br /> 0 Q 114 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 orIXn <br /> t <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years - <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 'DRef®rred Li CIWMB Enforc J <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators nce d. <br /> O O Other: § - <br /> Comments <br /> an�� Q.,. - J�S <br /> A:!o D ro'.-n t� 71n > d i <br /> t I&a'A'?'s T v,'o 6 �� <br /> • � ��- �r �.�. �7 ��� W��ti �.�,..c. (M ova. . <br /> Inspection Form Included: Q <br /> Comments Included: Q — —� ----- ` �- <br /> usiness Rep's Signature Phone Number Insp tor's Signat a _- _ Phone Number <br /> INSTRUCTIONS ON BACK ! Correct:* Incorrect: X ! E IX A, TI E1- I 2I 3 I 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />