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Waste Tire Suey & Inspection Re oroolnspection Report Number <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 t - � 0 3 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ! ILI �j !1 I Q Routine 0 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Jit` �� 3.\h t 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ; <br /> _- Inspected By Inspector <br /> Physical AddressC 1 �,�P�� r t iJ�<� <br /> / 1 <br /> Street e 4 Inspection Date l O <br /> �,� 2. ) Cr <br /> City State ZIP Code Time <br /> -In Time Out <br /> Business Rep Ilk' /o�j Title Q AM <br /> // JOAM <br /> 0PM m ' QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whol�lq (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PT <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude `� . <br /> 0 Closed 0 Altered <br /> GP$ 0 Hauler 0 Indoor <br /> O 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 Carilealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler ® Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V <br /> 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 Q 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 I 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 , ( •j 4 40( i • .V C� a �,�i �6, <br /> r i <br /> 47 <br /> ! " ( � �'•C- ..� (<< C'�'�...._ <br /> 1 n f _� <br /> L/ <br /> 100 N F ✓'i�f� / l r tit t ( T <br /> i <br /> Inspection Form Include <br /> Comments Included: � - <br /> Business Rep's Signature Phone Number Inspector's Sisnatur Phone Number <br /> - - --- - - � r 62081 <br /> INSTRUCTIONS ON BACK Correct:9 Incorrect: X /1, \// x1 E 1. ,',0, <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA <br />