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Is ection Report Number <br /> Waste Tire Suoy & Inspection Repor� _n_ p p _. - <br /> �� �- State of California ' <br /> ''✓..>" CIWMB 181(New 04/04) Survey Form - Page 1 <br /> " California Integrated Waste Management Board <br /> Part A Surve BLUE OR BLACK INK PEN <br /> ''� <br /> ,te�.� ,�'h�n"r�rar <br /> TPID- ( 1 Inspection Type (Fill one) <br />} Site Suffix: L i (d Routine Q Re inspection Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier 10 CHP Q CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name --- <br /> t <br /> Inspected p Y Inspector <br /> ' f <br /> Physical Address J ' f 1 f. <br /> vi <br /> Street <br /> ` - <br /> Inspection Date <br /> / <br /> t <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title d O AM m Q AM <br /> 0PM m � L�I 0PM <br /> I tl I <br /> Operational Status Business Role <br /> rp�('l,rv�S 3rrrpiq <br /> "(Fill one only) (Fill all that apply) <br /> ® ACtIVe (DGenerator <br /> O Closed <br /> GPS Latitude O Hauler <br /> Q Inactive End-Use Q Planned <br /> )%r <br /> t' <br /> MFAMMI <br /> r <br /> Q New Tire Dealer O Auto Repair &Trucking Fleet O Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer O 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 /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 1 Date FT] <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'orEXT) <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 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q 1 O (Other: § <br /> Comments <br /> � _ t � "! y' • ;:" ,r;t 6r1.�( ,. y...�,t..�T'-tom-'.- "=._`q•._`.- . , <br /> T + <br /> °rfi1.�-s :.t' /,'e:%li ('(• `i.i ��`[; ! ( + - �.J(.?l� ^- 'i / t✓'l 'r !r1!- I +- -- :(,{�f:,y 1 I /' <br /> fl ft jt/ �- <br /> !�, k,1.(:' <br /> j <br /> / 62081 <br /> INSTRUCTIONS ON BACK Correct: incorrect. ; �/ F7 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> I <br />