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Ins ection Re ort Number <br /> Waste Tire Su�y & Inspection Repor ___ p____ _ -p_ <br /> ■ 'W State of California r <br /> CIWMB 181(New 04/04) Survey Form Page 1 Q _ - _ <br /> California Integrated Waste Management Board -- <br /> Part A- Survey <br /> BLUE R BLACK INK PEN <br /> Business Profile Inspection Detailsr <br />} TPID- % Inspection Type (Fill one) <br /> � . _ <br /> Site Suffix: i � 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> , i <br /> Physical Address <br /> Street <br /> Inspection Date <br /> `' _ , .) <br /> ---- -- --- Time'Out <br /> Time In <br /> State ZIF Code <br /> -- <br /> Business Rep Title AM <br /> w T _L __._I PM �.._.... .___.:. O PM <br /> – -J <br /> Storage TypeOperational StatusTireTYPe us <br /> }(Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PT <br /> ` 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> =--. —L <br /> o0 Hauler Indoor <br /> Closed (� Altered <br /> GPS Latitude E-E , � Q Inactive (� Truck <br /> Longitude 1 �� , �� 0 Planned 0 OTR End-Use Container <br /> Business Type (Fill all that apply) tt 'th„ m tl <br /> 0 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 /> V A li HAULING AND MANIFEST REQUIREMENTS 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 M / M / m <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 1 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <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 In compliance - No Violations <br /> 0 0 !1 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O p <br /> 0 0 Other: § -_ <br /> Comments a ; 'A <br /> } <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - -- _ - <br /> Business Rep's Signature Phone Number Inspector's Signatures , Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X � 1 I Ck ,A, �:i; l_ F_' .) - 62081 <br /> I e : E ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />