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__R A., .AIIIIII+.. -W $ <br /> .: Waste Tire Sur y & Inspection Report JJnspectioAn Report Number <br /> CIWMB <br /> 181(NewCaliforniSurvey Form - Page 1 { i - { V i 0 5 {f 8 <br /> _ CIWMB 181(New 04104) <br /> California Integrated Waste Management Board -- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> AIIIIIIIIIIIII Inspection Details <br /> TPID- I �� �. - �.: Inspection Type (Fill one) <br /> Site Suffix: I j ( �• 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Jt.ifAi (,f,tY� �. t`)�`.v�-� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 <br /> _ Inspected By Inspector <br /> (Physical Address - FC� e <br /> I -1 P�V1_ �r I <br /> Street <br /> i. Inspection Date <br /> Ci State ZIP Code Time In Time Out <br /> Business Rep f Title l AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (WholelPTE) (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> ' v ® Active 0 Passenger 0 Generator 0 Outdo r <br /> 0 Closed 0 Altered11 <br /> GPS Latitude � - 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> fiat apply) <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 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 0 / FTI / 0 <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 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 <br /> (i <br /> 1 + y`1• r j 'Ef i j7�i.�'� t '':1�-;�✓� 'f,�� �K � - 1 tri' ���.} f Q ✓: - .i't � --. <br /> Inspection Form Included: 0' <br /> Comments Included: 0' <br /> Business Rep's Signature Phone Number Inspector's Signatur Phone Numb&r <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X E X1 A MIP I L I EIJI3 1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />