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Waste Tire Su. & Inspection Repor nspection Report Number <br />State of California <br />�CIWMB 181 (New Survey Form - Page 1 ._-... $ 4 <br />California Integrated Waste Management Board ____.__ ....-.... _ .__,.. 6..___4_] <br />Part <br />Part A - Survey / BLUE OR BLACK INK PEN <br />TPID - <br />Site Suffix: <br />Local -( <br />Identifier: i ,� y� , } .. c 'Vi. jU. <br />Business or Facility Name <br />Inspection Type (Fill one) <br />Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Inspected By Inspector <br />f ) <br />Phy§ical Address <br />Street" / <br />% - Inspection Date <br />( <br />City State ZIP Code Time In Time Out <br />Business Rep Title OAM m O AM <br />® PM EEI: <br />W <br />O PM <br />Operational Status r Business Role 9 <br />�r r�' �^r«,4 V <br />(Fill one only) ;:� ) (Fill all that apply) <br />f 0 Active�� f+'i; �a Generator <br />I <br />GPS Latitude m T 00 Closed <br />0 <br />Inactive <br />o <br />Longitude - F7F_1 , I 1 0 Planned <br />0 New Tire Dealer <br />0 Auto Repair <br />(!�' Trucking Fleet <br />0 Government <br />0 Retreader <br />0 Used Tire Dealer <br />0 Auto Body <br />0 Car Dealer <br />0 Collection <br />0 Crumb Rubber <br />0 Service Station <br />0 Hauler <br />0 Agriculture <br />0 Shredder <br />0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers, <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />1 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 <br />' Other: § <br />Comments 'l� o <br />0 Hauler <br />0 End -Use <br />Dismantler 0 Tire Derived Fuel <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Date <br />m 0 m <br />(Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />0 In Compliance - No Violations <br />Phone Number <br />INSTRUCTIONS ON BACK 'Correct:e Incorrect: X , wi ,I 62081 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA © ■ <br />