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■ :63 Waste Tirek. & Insp ection Re spection Report Number <br /> it <br /> State of California � � � _ �--- ---- _,.__.. <br /> CIWMB 181(New 04/04) D �" I � � �y <br /> California Integrated Waste Management Board Survey Form - Page 1 I ' - =S <br /> Part A Survey ..... .....Business Profile <br /> BLUE OR BLACK INK PEN_ <br /> Inspection Details <br /> TPID- <br /> L <br /> Inspection Type (Fill one) <br /> Site Suffix: � <br /> Routine 0 Re-inspection Referral <br /> --- _ � 0 Observation <br /> ---- <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> Sfafe Zip Code Time In Time Out <br /> i Business Rep Title _i -- 1 ' <br /> O AM <br /> ` • j O AM <br /> L � ' ��L0 PM ' � O PM <br /> -- -- _�._ —T------I - _ <br /> ". Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply)! (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger Q Generator 0 Outdoor <br /> o 0 Closed 0 Altered 0 Hauler 0 Indoor <br /> GPS Latitude <br /> 0 0 Inactive 0 Truck <br /> Longitude F-71 B , I 1 0 Planned 0 OTR 0 End-Use 0 Container <br /> .,.,71 -= <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel l <br /> Q) 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 /> — _ <br /> V A HAULING AND MANIFESTREQUIREMENTS - - <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0m 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date / <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB m m <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Tri within 90 days 0 p Lo (Required for NOV or EXT) <br /> Logs g y <br /> 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/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire e End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK Correct:® Incorrect: ��,�P L 62081 <br /> 13 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® r <br />