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Waste Tire Sur*y & Inspection Report IWspection Report Number <br /> State of California I ■ <br /> CIWMB 181(New 04/04) f/� A wry <br /> California Integrated Waste Management Board Survey Form - Page 1 1 2 1 0 13 5 3 0 y <br /> Part A Survey BLUE OR BLACK INK PEN <br /> _. _... <br /> tt �FIoflleInspection Details <br /> s ( . - <br /> Pe Suffix: (� 1-7 <br /> Q � Inspection Type (Fill one) <br /> SRoutine Q Re inspection Q Referral 0 Observation <br /> Local — If Referral,choose referral type(Fill one) <br /> Identifier: �� L E j / 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name — - - <br /> Inspected By Inspector <br /> . <br /> -ITT] <br /> Physical Address <br /> street _ <br /> Inspection Date ra <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM AM <br /> EE : <br /> F 0 PM [1:1 : EF- <br /> 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> Fill one only) Fill all that a I (Fill all that apply) (Fill all that apply)' <br /> ( Y) ( pp Y) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> D � Closed 0 Altered GPS Latitude W F-17= <br /> "( 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck Longitude - � 0 planned D OTR 0 End-Use 0 Container------E - LLU <br /> 0 New Tire Dealer 0 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 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 /> 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 0 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 Other: § <br /> Comments 1� <br /> f <br /> Inspection Form Included: 0 <br /> Comments included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> / <br /> I - _ 62081 <br /> INSTRUCTIONS ON BACK Correct:, Incorrect: X v 1. <br /> White Cop ,14 <br /> !. ; <br /> ■ - - _ _. ® ■ <br /> Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />