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Waste Tire Sly & Inspection Repo", Inspection Report Number <br /> State of California <br /> aaaam CIWMB 181(New 04/04) Survey Form e 1 Il - 1086944 <br /> California Integrated Waste Management Board y - Page _. 4444. - 4444 4444 <br /> Part A-,Survey T BLUE OR BLACK INK PEN <br /> Pp <br /> tails <br /> Busmesa�Prafile.i Inspectitails <br /> __ — — <br /> ^ Inspection Type (Fill one) <br /> TPID- I <br /> Site Suffix: [j] 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> � <br /> Identifier: ) I l� I <br /> I._ { + ; I , 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical <br /> Street Inspection Date A( ,.7�City State ZIP Code Time In Time Outs <br /> Business Rep -1 Title' C�jj <br /> 0 AM <br /> 0 AM <br /> PM .}� 1 O PM <br /> Operational Status are;` y�pe' Business Role 7Sfaraje Type <br /> I t. (Fill one only) (Fill all that'a'pp(y)a (Fill all that apply) (()II al►that apply) <br /> °'� Active Passenger (P Generator ( Outdoor <br /> D 1 0 Closed <br /> GPS Latitude .FT-1 0 Hauler 0 Indoor <br /> 0 Inactive <br /> Longitude - 0 Planned 0 (�Tf7 0 End-Use 0 Cohtairler <br /> _ <br /> Business Type. (Fill all that apply) -- <br /> 0 New Tire Dealer (D Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body ' Car Dealer 0 Collection 0 Crumb Rubber <br /> Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> - - - - - - - ---- - - - - - - I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility E FORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <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 /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Req � <br /> 0 0 14 CCR 18459.3-Retention of Comprehensive 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 ! <br /> In Compliance - No Violations <br /> 0 0 Other: § p <br /> Comments ! t <br /> Inspection Form Included: 0'l "y' <br /> r, ,: <br /> Comments Included, 0 "- -- -- _ _ <br /> Su'"sines Rep's Signature Phone Number In '„ „ ;,•� tib � )Phone Number -. <br /> -: <br /> �'" / _ __� � 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: ; y d" h <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />