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Waste Tire Su&y & Inspection Repor Inspection Report Number <br /> MU <br /> State of California <br /> CIW <br /> MB181(New 04/04) Survey Form - Page 1 t - 1 0 0 6 40 <br /> California Integrated Waste Management Board ---------- --------- --- <br /> Part A- Survey BLUE OR BLACK INK PEN <br />} TPID- / _ _, '_- Inspection Type (Fill one) i <br /> Site Suffix: 1 J I Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local — If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> I-- -- —- __,: i <br /> Street Inspection Date / I j I i <br /> F —) Time In _ Time Out <br /> State ZIP Code <br /> - _ <br /> Business Rep TitleO AM AM <br /> ® PMm ' Er 0 P <br /> Operational Status Tire Business Role Storage Type <br /> (Fill one only) (Fill a �✓ ' � (Fill all that apply) (Fill all that apply)' <br /> 0 Active QiP "� ra�F� 0 Generator 0 Outdoor <br /> D Closed A�"� t,� �t���' <br /> GPS Latitude [ 0 t �)�✓rgxlF <br /> 0 Hauler 0 Indoor <br /> 0 Inactive aT <br /> O t,ri bi " <br /> Longitude - 0 Planned O'OTR End Use D Container <br /> 0 New Tire Dealer Q 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUSp <br /> V <br /> A j HAULING AND MANIFEST REQUIREMENTS 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 <br /> § <br /> O O 14 CCR 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB 0 m m <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/GIWMB Fnforcernent <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities y'r <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: § <br /> Comments <br /> J <br /> ( ' / G' M _ <br /> - ( - i' ''i ...i .. f ~•1.., \�, I „�A t��/lam' - ` _ l -r A <br /> tl , <br /> - I 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: Le <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />