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nsF ion Report Number <br />Waste Tire Sur ...y Onspection Report <br />LOII3. StateBof California Survey Form -Page 1 f 10 i,/ V <br />CIWMB 181 (New 04104) <br />California Integrated Wastb Management Board — _ <br />Part A - Survey BLUE OR BLACK INK PEN <br />TPID . Inspection Type_jFill one) <br />Site Suffix: - -7~ ? �� ® Routine 0 Re -inspection 0 Referral 0 Observation <br />Local ( ( If Referral, choose referral type (Fill one) <br />tIdentifier: I tV1t�� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />4th Business or Facility Name i Inspected By Inspector <br />1 f f <br />Physical Address <br />"J iJ '.i (' <br />Street ` <br />I <br />(-A ns ectlon ate <br />.,_), I � <br />City State ZIP Code Time InFTime Out A <br />Business Reb Title m AM 0 ANY' <br />PM <br />0 PM 0 <br />I JI �,�,� f�� , i': i,,.;;1 -O erational <br />- - - <br />p Status T re Type Business Role Storage Type <br />Tiunt (W le (Fill one only) (Fill all that apply] (Fill all that apply) (Fill all that apply) <br />`re o _ �:, /� <br />0 Active 0 Passenger ® Generator 0 Outdoor <br />O 0 Closed 0 Altered <br />GPS Latitude 0 Hauler <br />m <br />o 0 Inactive 0 Truck <br />Longitude- 0 Planned OTR End -Use <br />Business T <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler <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 Q Other <br />'—Part B -inspection-cif Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A I HAULING AND MANIFEST REQUIREMENTS <br />- <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />1_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 />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 <br />Other: §,' <br />0 Indoor <br />0 Container <br />",am" <br />Tire Derived Fuel <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />0 Referred I CIWMB Enforcement <br />0 In Compliance - No Violations <br />Comments <br />r <br />vi t•-1 ` i, i ✓1 ' 'J I �� V i t vj r t_ <br />lily r , r i !'.Irty'�.i 1�';�'' 1/I✓����:',! ),� � i_iI )1 1�_,;�t�, <br />ispection Fo „ <br />Comments Included: i. <br />0, Business Rep's signature Phone Number Inspector's Signaturt <br />_ - <br />INSTRUCTIONS ON BACK Correct:* Incorrect: X� X A M P L I 1 3 <br />White Copy: CIWMB Yellow Copy Operator Pink Copy: LEA <br />�I <br />Phone Number <br />62081 <br />