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r <br /> Waste Tire * & Inspection Rep nspection Report Number <br /> State of California <br /> ti CIWMB 181(New 04/04) S u rvey Form - Page 1 _ <br /> - 3 0 _.0 <br /> Part A- Survey p K INK PEN <br /> E <br /> Business Profile Inspection Details BLUOR AC <br /> TPID- r—/ Inspection Type (Fill one) <br />} Site Suffix: I � l `� r`, I �i � O Routine Q Re-inspection Q Referral Q Observation <br /> LocalL(7' <br /> If Referral,choose referral type(Fill one) <br /> Identifier: `)a .{��L 1 ��i�, Q CHP 0 CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name •° Inspected By Inspector <br /> �� ' . �ta� ���lt'1�li►IFi � 1- t , I 'f <br /> Physical Address L <br /> Street Inspection Date <br /> Citv State ZIP Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> 0 �I J % i f ( /. 0 P m � 0 P <br /> Operational Statusf(,F,, <br /> Ire Type Business Role torage Type <br /> Tire Count (Whole/PT (Fill one only) ll all that apply) (Fill all that apply) Fill all that apply) <br /> 1 1 :3– Q Active Passenger Q Generator Outdoor <br /> Latitude m d O Closed O Altered - <br /> GPS 0 Hauler Indoor <br /> D Q Inactive 0 Truck <br /> Longitude – Q Planned O OTR O End-Use ontainer <br /> Business Type (- <br /> mmkow- <br /> 0 New Tire Dealer O Auto Repair Q Trucking Fleet O Government O Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> O Service Station 0 Hauler O Agriculture Q Shredder (3 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 /> Notice Of Violation 0 Extension <br /> O 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 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> O Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O 0 14 CCR§18461 - Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance No Violations <br /> O 0 Other: § <br /> {} 1 <br /> Comments <br /> r <br /> Lf A {"4'` �( l <br /> Inspection Form Included: O <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X X _A � 11P L 1 2 3' 62081 <br /> White Co CIWM. Yellow Co Operator Pink Co LEA <br /> PY PY P PY <br />