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Waste Tire Su ay & Inspection Repors Inspection Report Number <br /> Stateof California Survey Form - Page 1 1 1 1 0 f V 3 8 0 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> �Business Profile Inspection Details - <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 0 3 0 O r Q 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Q/z LY2 N 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - <br /> ,� Inspected By Inspector <br /> Physical Address 3 13 0 FA--1 <br /> Inspection Date / / 0 7 9 <br /> Time In Time Out <br /> Business Rep e© Title ® AM 0 AM <br /> J"4' G/�-�C-. OuJGcP� / 0 PM V 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use ® Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 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 /> -- ------ -__. -.-.------------ <br /> A HAULING AND MANIFEST REQUIRE <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 /> O D 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> -- -- -- _------- ----- <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 - - - - <br /> In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: 0 -- <br /> Rep's ature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK i � <br /> Corr ct Incorrect AIMiFL � <br /> s2os1 <br /> � <br /> : 123 <br /> Whiten_ --- -- - --- ---- --— <br /> Copy: IW Yellow Copy:Operator Pink Copy:LEA <br />