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Waste Tire Su0y & inspection Report1_ 7 <br /> ction Report Number <br /> State CIWMB <br /> f 181(New <br /> Survey Form - Page 1 - i <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile <br /> TPID- - Inspection Type (Fill one) <br /> Site Suffix: t � Q (i l ® Routine Q Re inspection Q Referral Q Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: <br /> h, •� 7",q�. / <br /> /e•" r f l +./ t. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> Y1 l ror/tri '-( I IiE <br /> Physical Address I fLLL......--- t � �f'�'tl <br /> Aj <br /> Street <br /> f i Inspection Date <br /> 1 t r <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM 9 O AM <br /> QPM QPM <br /> Operational Status Tire Type w)i Business Role Storage Type <br /> (Fill one only) (Fill all that apply)` (Fill all that apply) (Fill all that apply) <br /> t 1 C) <br /> Active _ Q Passenger Q Generator Q Outdoor <br /> Latitude 10 Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> _ [ <br /> ��� Q Inactive Q Truck <br /> Longitude - � � I � Q Planned Q OTR Q End-Use Q Container <br /> Susiness Type (Fill all that apply) ' <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q 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 /> ----- Q Notice Of Violation Q Extension <br /> Q 1 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date 17 / 71 / m <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> + r t <br /> — <br /> ( � f. <br /> It <br /> Inspection Form Included t , <br /> p ;t r F"+", 4 t; r r^<`'''+'i+n+ d'"�` ✓'r rw 1 <br /> • ),�� <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number inspector's Signature Phone Number <br /> // 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X V� IA'MFP <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA ■ <br />