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WaFte Tire Susy & Inspection ReporInspection Report Nu. .mber <br /> State of California �/� <br /> CIWMB181(New 04/04) Survey Form - Page 1 j l 9 - 1 01_0 51 81 <br /> California Integrated Waste Management Board ---_- --_-. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 7 �. Inspection Type (Fill one) <br /> Site Suffix: ® 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 /> I <br /> Physical Address "J <br /> Inspection Date <br /> Time Out <br /> Time In <br /> State ZIP Code _- _ <br /> Business Rep Title Q AM Q AM <br /> { QPM Q PM 5 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PT { (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> ir 0Active 0 Passenger (jo Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude . TTI <br /> J§, 0 Hauler 0 Indoor <br /> D 0 Inactive 0 Truck �% <br /> Longitude – 0 Planned ."0 OTR 0 End-Use 0 Container <br /> 0 New Tire Dealer 0 Auto Repair ® 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 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 /> 4^ <br /> Comments '�17 / <br /> Xi r�C I r" Pti'i I?C7 i� � `•!S r �;_t( 1 ����l U ij l l: : / . YI C)( �a 1 <br /> �t►'c<7u E.l !j '_ ki,f.;u-q 61 hot)c r`lt:; ' - <br /> �liGI� yb 1 - ty')ani �f � �S_ ftr►i h:'.k'cis — iij(dr F'li.:� ` <br /> r <br /> All Q1 r'i I.C �Ii t ` covAlf), All- <br /> Inspection <br /> ll_Inspection Form Included: 0 <br /> Comments Included: - <br /> qsmess Rep's Signature Phone Number - Inspector's ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON"BACK Correct: Incorrect: X E XIAMIPILIEI 111273 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />