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Waste Tire y & Inspection Rep If,spectiof, Report Number <br /> >; a State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 18 - 1 0 1 3 4 8 8 <br /> California Integrated Waste Management Board -- ------ - - - -- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> 1 TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 / 1 - 116? 1 7 <br /> ® Routine Q Re-inspection 0 Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: �-/ / 1.7 ;� �z 0 CHP 0 CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> I? <br /> Street Inspection Date <br /> IX I Time In <br /> City State ZIP Code Time Out <br /> _ _ <br /> Business Rep Title ] : F ® AM 0 AM <br /> f-~ 7lopm > O PM <br /> i <br /> Operational Status[Fill <br /> re Type Business Role orageType <br /> Tire Count (Whale/PT <br /> (Fill one only) all that apply) (Fill all that apply) (Fill all that apply) <br /> E� ., <br /> 0 Active 0 Passenger Q Generator Q Outdoor <br /> Q Closed 0 Altered <br /> GPS Latitude m • Q Hauler O Indoor <br /> - Q Inactive 0 Truck <br /> Longitude – Q Planned O OTR Q End-Use O Container <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other : E 4 "y C'04-- j <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation Q Extension <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date Fn / M / M <br /> O Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q ® 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> Q O Other: § <br /> Comments ' ' <br /> J[�!pcy. r gQ - TtJt(�-l7 fir`/ ltt,..icGtrl :.CIc /L�t' fJ1� rr�C7 �J � �ct�JlQ <br /> eK <br /> nspection ForoIncluded: Q, _ - - <br /> Comments Included: O Business Rep's Signature Phone Number 1 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X F XIA MP L E f 2 3 62081 <br /> White Copy:CIWMB cony 0,�-r ilor Pink Copy:LEA <br />