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Waste Tire Surly & Inspection Re Ort nspection Report Number <br /> State rnia CIWMB <br /> f81(New Survey Form - Page 1 1 7 - 1 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- r Inspection Type (Fill one) _ <br />} Site Suffix: I /1 '� ( / t. O Routine O Re-inspection Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP Q CIWMB Q Complaint @ Educational Visit O Other <br /> Business or Facility Name t: I Inspected By Inspector <br /> Physical Address t <br /> Street <br /> Inspection Date <br /> i <br /> - ? <br /> ( I e Time Out Time In <br /> City � State ZlP Code _ <br /> Business Rep Title ' `+ / 0AM O AM <br /> 0 PM 0 PM <br /> _Itl'��1 tt tv(,t�< — <br /> ,,,, Operational Status Tire Type ;.tf W; Business Role Storage Type <br /> (Fill one only) (Fill all that a(?pl (Fill all that apply) (Fill all that apply)': <br /> Active 0 Passenger O Generator 0 Outdoor <br /> D <br /> Closed 0 Altered ` <br /> GPS Latitude • <br /> Ei��� Q Hauler 0 Indoor <br /> Inactive Truck <br /> Longitude — Planned OTR O End-Use 0 Container <br /> Business Type (i al!thai apply) =: <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> Q Service Station @ Hauler O Agriculture O Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A-'HAULING AND MANIFEST REQUIREMENTS <br /> O Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / <br /> O O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O (2) 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> Other: § t.," ; I,,, <br /> Comments T,��# `� 11L�6'-` -'r! ;r <br /> r1-F1)' 1 3f: 41/( t�,r( �l;�%�)U ?i it��,;�f 6'>�:.tt:, (ti,' / �/� ►y (' �r, <br /> Jd r fir r� �tG <br /> Inspection Form 'Included: Q', <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature _Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X ,Imo, I L E I $ C i='! <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © In <br />