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.: . Waste T *-SuW & Inspection Reportspection Report Number ■ <br /> �mstate of <br /> CIWMBB181(New 04/04) Survey Form - Rage 1 4 - 3 <br /> California Integrated Waste Management Board <br /> Surve <br /> Business nss Profile <br /> y ' In��� tion Details BLUE OR BLACK INK PEN., <br /> TPID- I <br /> - � inspectionType`(Fill one) <br /> P <br /> Site Suffix: !O Q Re-inspection O Referral O Observation <br /> Localr� '' If Referral,choose referral type(Fill one) <br /> Identifier: O CHP O CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> r <br />� Physical Address <br /> Street <br /> Inspection Date <br /> � f � I Time In <br /> City State Z/P Code Time Out <br /> Business Rep Title AM AM <br /> � . � <br /> ®0 P - 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> C7 (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply)', <br /> The Cna_Ir�t I!!�I�olp/PT�� 0 �? <br /> ® Active 0 Passenger (5 Generator 0 Outdoor <br /> Latitude 0 Q Closed O Altered <br /> GPS �� . Q Hauler O indoor <br /> O Inactive 0 Truck <br /> Longitude - L-J O Planned 0 OTR O End-Use O Container <br /> Business Type (Fill all that apply) P. <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer Q Collection O Crumb Rubber <br /> Service Station 0 Hauler 0 Agriculture 0 Shredder a Other i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> i - — - 0 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 O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> O O 14 CCR§18459.1 (a)(b) (c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> PI <br /> , <br /> Inspection Form Included: O ' ' ' <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �, <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />