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Waste Tire Su*y & Inspection Repor* Inspection Report Number <br /> tWs <br /> State California Survey Form - Page 1 7 - � 7 <br /> CIWMBa 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- <br /> [Ejj <br /> Inspection Type (Fill one) <br /> Site Suffix: J V J ®,Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I <br /> Inspected By Inspector <br /> Physical Address <br /> I , <br /> Street / -7,11 <br /> City State Z P Code <br /> Time In Time Out <br /> Busines Rep Title 0 AM 0 AM <br /> —4 <br /> ( b`I ,t m � m0PM 0P <br /> L t C��i Operational Status i <br /> Tire Count(Whole/PTre Type 17 Business Role §torage Typ <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that ap <br /> J <br /> ® Active Q Passenger Q Generator Q Outdoo <br /> 0 Q Closed Q Alter'tc <br /> GPS Latitude Hauler Q Indoor <br /> 0 Q Inactive Q Truc <br /> Longitude — I Q Planned OTR End-UseJDCoutainpr . <br /> Busi_;V Fill all that app' <br /> Q New Tire Dealer Q Auto Repair @ Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m m <br /> Q 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 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 Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q (Other: § <br /> Comments ) >r <br /> VJJcry <br /> 7r Y"- ;l Yy l 7 d ,J V-)If <br /> k - ( 0ifl. 'JN r <br /> Inspection Form Included: Q <br /> Comments Included: Q = <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number __ <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X (g X A " !p I L I El 11 2 3 62081 <br /> White Copy:CIWMB Yu 111e% C<IIIy Pink Copy:LEA <br />