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r � <br /> Waste Tire Sury & Inspection ReportSpection Report Number F <br /> 1 ,c'.731 State of California `'- J A ,r1 <br /> $� A <br /> CIWMB 181(New 04/04) 5 1G1 0SurveyForm Page 1 " <br /> California Integrated Waste Management Board <br /> -- --- - - - - <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> TPID Inspection Type(Fill one) <br /> Site Suffix (3 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> -Physical Address LE - <br /> Street <br /> Inspection Date EE <br /> State ZlP Code Time In Time Out <br /> Business Rep Title AMO AM <br /> [E : <br /> . 0 PM FE : <br /> Ej­_", O PM <br /> J <br /> y aOperational Status Tire Type Business Role gage Type <br /> (Fill one only) (Fillall that app( (Fill all that apply) (Fill all that apply) <br /> 110 ®Active 0 Passenger Generator 0Outdoor <br /> isO <br /> P$ 0 Closed 0 Altered <br /> G <br /> Latitude1 <br /> 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - �� Planned 0 OTR 0 End-Use 0 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 O,Collection 0 Crumb Rubber_ <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> 1 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> -- <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 /> M / M / m <br /> 0 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 Q 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 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 j Other: § <br /> Comments <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: X <br /> ■ _._ _N © ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />