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// _ <br /> f <br /> Re <br /> nspection ort Number <br /> s W ste Tire Su ` A Inspection .Rep <br /> Feet: StateB181(New Survey Form - Page 1 - 1-0 06 3 4 . . <br /> liie,m CIWMB 181(New 04104) � J <br /> California Integrated Waste Management Board �7 r <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- J Inspection Type (Fill.one) <br /> Site Suffix: f 3 '` �� r/ Q Routine d 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 V' Inspected By Inspector <br /> physical Address ® / 101d <br /> Street Inspection Date J '7 / F511 /F51. / <br /> Time In <br /> I Time Out <br /> City State ZIP Code <br /> Business Rep Title 0 AM 0 AM <br /> r- mm0PM mm DPM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that ap,V) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> Active Q:Passenger Generator @ Outdoor <br /> O Q Closed Q:Altered <br /> GPS Latitude. m 'm'�� Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - L 1 Q Planned Q OTR Q End Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair V Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 FacilityENFORCEMENT STATUS ^� <br /> G , <br /> V '; A I HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q QPRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> I <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <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 /> 0- <br /> _.-._.Q- @ 14 CCR§18462•-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> Q Q Other: § <br /> Comments �1� S_. . i` fi, �. , I` �F �U! 2 j fit', ' t:�. �: A- <br /> - o_3 oq-/ <br /> ��,a Ln ?`-✓ 1 � a� l.tom,d 4. r� ( �•_ �y'G!'� .�"7` l_._� ��'-f`✓"� " <br /> /} <br /> Inspection Form Included Q; <br /> . - - <br /> __._. <br /> Comments IncludedQPhone Number Reps Signature Phone Number Inspector'sSignature _ <br /> �/ XJA 62081 <br /> INSTRUCTIONS ON BACK .L-Correct:I* Incorrect: X ;f U ,; .A SN I� 1. <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />