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Y9!te Tire Sure & Inspection Report ;spection Report Number <br /> ifornia <br /> CIWMB181(New <br /> 04/04) SurVeV Form - Page 1 �_ 1 6 - 1 0 .j 3 <br /> California Integrated Waste Management Board J g - - --- <br /> Part A- Survey' _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: <br /> Q Routine Q Re inspection Q Referral Q Observation <br /> Local -- If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> . I <br /> Street -� Inspection DateEL <br /> City State ZIP CodeTime InTime Out <br /> Business Rep Title O AM O AM <br /> / '/ • T <br /> � O PM PM <br /> Operational Status ire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply)', (Fill all that apply) (t=ill all that apply) <br /> Active Q Passenger Q Generator Q Outdoor <br /> --�T Closed Q Altered <br /> Latitude <br /> oor GPS ° Q <br /> � <br /> Q Inactive Q Truc <br /> ° k <br /> � F� , <br /> Longitude — Q End Use Q Container <br /> Q Planned Q OTR <br /> Rusin s.Type (Fill all that app1Y) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 ENFORCEMENT STATUS <br /> _. - <br /> V ' A HAULING AND MANIFEST REQUIREMENTS <br /> --- -- -- Q Notice Of Violation Q Extension <br /> I ,[ I i <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 /> Q Q 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 Q 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 Q In Compliance - No Violations <br /> Q OI §Other: <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: Q _ > <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> �- 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: XA IV. d. <br /> _. _. ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />