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Report Number <br /> Waste Tire Su & Inspection Report"pection ■ <br /> ■ % State of California 4 2 <br /> = .uy. <br /> CIWMB 181(New 04/04) Survey Form - Page 1 , Il 0 <br /> California Integrated Waste Management Board <br /> -- BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business.Prpf' , , e Inspection Details <br /> TPID- ( Inspection Type (Fill one) <br /> f Site Suffix 11 3f Oa� Q �� (V Routine Q Re-inspection Q Referral Q Observation <br /> [ . 1 <br /> Local - If Referral,choose referral type(Fill one) <br /> Identifier: �Q n .�,aq, i L� ( 1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street p <br /> ,-- � ' � Ins ection Date <br /> `` ---- t?lte� �l .__ _r 1_ _ <br /> 9 � Y 0 t ' Time Time In Out <br /> I r- AM ;r� AM <br /> Business Rep Title <br /> 1 <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply);: ( ill all that apply) Fill all that apply) <br /> rF pPY) ( IPY) <br /> Tire Count(Whole/PTE) <br /> a ° ! Q Active Q Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered <br /> Q Hauler Q indoorLatitudeGPS QInactive QTruck <br /> LIJ <br /> Longitude F-177-17 10 <br /> Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) bcr°:u , trel". <br /> Q New Tire Dealer Q Auto Repair Q 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 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility 1 ENFORCEMENT STATUS '- -- - <br /> V A j HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> FPRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> 14 CCR <br /> Q Q § 18459.3-Retention of Comprehensive Trip Logs 3 years 18459.2.1 -Submittal of Comprehensive TripLogs within 90 days <br /> Q Q 14 CCR§ I <br /> 4 CCR 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q IQ 1 § Y <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q j Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (Z In Compliance - No Violations <br /> Q Q Other: § I —_- — _ <br /> --- —I <br /> 1C <br /> Comments �rJL� \ Q t i 1 , :1, �',• f 1 , <br /> ` 7 <br /> Inspection Form Included. Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> - - - -. 62081 <br /> INSTRUCTIONS ON BACK Correct:*/ Incorrect: X � � �A �l{�' (r-, �y � <br /> 0 White Copy;CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> I <br />