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fns. section Report Number <br /> Waste Tire S y &' Inspection Repo p_- _ _p <br /> California State of California � 31 A <br /> rn t t SUrvey Form - Page 1 3 E t -4 R <br /> CIWMB 181 New 04/04 _ <br /> a i <br /> is Integrated Waste Management Board - --- <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> BusiPr <br /> ness ilel i w fia, „f„s,G �nt? P�tan Details <br /> ;a <br />} TPID- } � Inspection Type (Fill one) <br /> Site Suffix: <br /> Q Routine Q Re-inspection Q Referral Q Observation , <br /> LocalF\ sJ <br /> l — If Referral,choose referral type(Fill one) <br /> Identifier: t) 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> M kA <br /> --- <br /> Business or Facility Name} <br /> t, Inspected By Inspector <br /> E -- <br /> Physical Address / <br /> 1^ <br /> t )'� <br /> Street { l f Inspection Date <br /> City State 21PUode Time In Time Out _ <br /> Business Rep: Title ' O AM �= : [ <br /> Q AM <br /> 0 PM .. O PM <br /> ”— T_J IOperational Status Tire Type Business Role Storage Type <br /> h (Fill one only) (Fill all that apply)', (Fill all that apply) (Fill all that apply), <br /> Q ActiveQ Passenger Q Generator Q Outdoor <br /> Latitude _LLI Q Inactive Q Truck Halder Indoor <br /> GPS - _ _- o Closed Altered Q Q <br /> 0 0 <br /> Q Planned Q OTR <br /> Longitude — � � Q End-Use Q Container <br /> 9 , <br /> Business 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 I I <br /> Part <br /> Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> C V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q 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 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / FT] <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT)- <br /> -------- <br /> Q 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> -- — <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> 0 1 0 Other: § ----- <br /> Comments <br /> (i i f -,( E,l / I t ��� g✓ i 1 ! �3� i i � �) ' �.r ,' i_f>�j(.�(, � L 1�.�'-- f I/ �......_ <br /> 16CR <br /> I - 1%l��1"f C! l��J l�l%t G - L r[ - <br /> 4 <br /> Eris ectFoi arm Incliurie t <br /> Comments Included. Q "—" - _... _`__. _ �w _ _ �� . _. <br /> Business Reps Signature Phone Number 1n "f tw:i _Phone Number r <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X Ak E �� ;' 1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />