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Ins tiort Number <br /> Waste Tire Sufy & Inspection Report_-_ pec_-on Report <br /> State of California 1 <br /> CIWMB181(New 04/04) Survey Form - Page 1 i -- - 0 a <br /> California Integrated Waste Management Board -- .- --- ' . -! <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> r UP, <br /> TPID- Inspection� � � % n - � � Inspection Type (Fill one) <br /> � "1- <br /> Site Suffix: 1/ , �-f O Routine Q Re-inspection Q Referral Q Observation <br /> Local r -- - - If Referral,choose referral type(Fill one) <br /> Identifier: O CHP O CIWMB Complaint Q Educational Visit Q Other <br /> r_ <br /> Business or-Facility Name Inspected By Inspector <br /> c._. J <br /> Physical Address <br /> _ L <br /> 1 <br /> Street 1 J <br /> Inspection DateEr ) <br /> City State Zlp Code Time In Time Out <br /> Business Rep Title � � AM ( � AM <br /> --� - 0 P 0 P <br /> r <br /> "fire . <br /> Operational <br /> I Status` Type <br /> BuieoleSage <br /> ae <br /> FI one only) (FIhat apply'" ( ll all that appy) ( loalthat apply)': <br /> CountVhole,t <br /> 1M 9 Active O Passenger 0 Generator 0 Outdoor <br /> ---------- <br /> 1 „M O O Closed Q Altered <br /> Latitude . <br /> GPS Q Hauler 0 Indoor <br /> C Q Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR Q End-Use 0 Container <br /> mss. .. <br /> ® New Tire Dealer Q Auto Repair O Trucking Fleet O Government Q Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder O 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 /> Q 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 /> 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 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 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 Q In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> -> y=_ <br /> 70 <br /> Inspection Form Included: <br /> i <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 � Iu' 4.. l L <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />