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Waste Tire Sway & Inspection Repora Inspection Report Number <br /> State of California <br /> ,+---- <br /> CIWMB 181(New 04/04) <br /> Survey Form - Page 1 1 5 - 10 i 0 8 L <br /> California Integrated Waste Management Board - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile A Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I I I �' > 6 0 f Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> f <br /> Physical Address it i�� I > %i ' '. '> , , /Z 1 �� <br /> Street <br /> Inspection Date '��i I / / / FT7 <br /> Citta State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM I O AV1 <br /> � . // , / m • 0 P �I 0P\1 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) h (Fill one only) (Fill all that ap (Fill all that apply) (Fill all that apply) <br /> �J ® Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude m • 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truc <br /> Longitude — FTT� d I 1 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Ty: <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 /> M / M / m <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 <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signatur Phone Number <br /> - <br /> INSTRUCTIONS ON BACK Correct:� Incorrect: X � r. xT M,�,I P L 1 2 3 620°1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />