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spection Report Number <br /> Waste Tire Su' y & Inspection Reportn <br /> State of California <br /> WA - <br /> CIWMB181(New 04/04) Survey Form Page 1 I � 1 . <br /> California Integrated Waste Management Board ♦ 9 _ .. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: j t L F-U Ell ® O p O O <br /> J T�outine Re-inspection Referral Observation <br /> Local i'T` �- - - -- If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Address <br /> Physical f j <br /> • l fit,.. �- I <br /> Street _ Inspection Date <br /> I �1 ��� I <br /> City J State ZIP Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> � OPM0PM <br /> Operational Status Tire Type . <br /> ���, Bu�Role l 'Storage Type <br /> The Count(Whole/ -FuPT l rt�( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (2)Active O Passenger Q Generator O Outdoor <br /> 0 Q Closed 0 Altered <br /> GPS Latitude j 0 Hauler Q Indoor <br /> __�� 0 Q Inactive Q Truck <br /> Longitude — O Planned O OTR End Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O 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 - _ O Notice Of Violation Q Extension <br /> O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> 0 Q Other: § <br /> Comments (( 1 <br /> - -- - ji�ZYIQ l✓l <br /> A � ' <br /> r <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> `/ / <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: J` '`i � X A ,M P DE f 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> ` y <br />