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-Inspection Re ort Number <br /> Waste Tire y & Inspection Repp � <br /> State of California <br /> Uzu CIWMB181(New 04/04) Survey Form - Page 1i <br /> California Integrated Waste Management Board _ __.. . . .__.__.,.._. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile <br /> 2_ <br /> _ s . .�, <br /> TPID- Inspection Type (Fill one) <br />} Site Suffix. � ' �� � 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 /> S i to t <br /> Physical Address <br /> Street <br /> ' Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 0 PM <br /> Operational Status aI, ' ?� Business Role 'StorageType <br /> (Fill one only) (Ft�� i (Fill all that apply) (Fill all that apply) <br /> ��b Ct�ipfr <br /> a f 0 Active gip` "ill Q Generator 0 Outdoor <br /> I D 0 Closed A)��� � � <br /> Latitude („r <br /> GPS 0 Hauler 0 Indoor <br /> O 0 Inactive <br /> , ^"/ /& <br /> Longitude 0 Planned (� OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply)1r-te' <br /> 0 New Tire Deafer 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 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 m / m / m <br /> 14 CCR 18459.1 a b c -Tire Program ID Number from CIWMB <br /> 6 <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 /> I 0 0 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 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 0 In Compliance - No Violations <br /> 0 0 Other: § _ <br /> Comments <br /> P <br /> •J-'_:' � _ •v1 n i.:1_>h. <<. rte. - r �c C _ t c'� ✓� , � i a C' <br /> t - <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _... 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X AW I_�p. <br /> ■ White Copy:CIWMB Yellow Copy:opetator Pink Copy:LEA <br />