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E Waste Tire Suy & Inspection Report�spection Report Number <br /> a6i�a State of California n <br /> Surve ?' <br /> CIWMB 181(New 04/04) Y Form - Page 1 r -� <br /> California Integrated Waste Management Board y <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> ie <br /> I��tstrre4ss Praftle'; ` Ins action ls <br /> --- — <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: �� <br /> 1 / � ' # Routine Q Re-inspection Q Referral Q Observation <br /> Local i a - — 7 If Referral,choose referral type(Fill one) <br /> Identifier Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> v <br /> Inspected By Inspector <br /> I <br /> -_ _.. . <br /> Physical 1"" d <br /> Address 1 <br /> Street VJ <br /> rt I Inspection Date(95 <br /> C 6 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title � __. 0 AM ( 0 AM <br /> _ 0 PM PM <br /> Operational Status Tire Type Business Role Storage Type <br /> The COUnt (Whole/PTE) (Fill one only) (Fill all that apply)1 (Fill all that apply) (Fill all that apply) <br /> 0 ® Active Q Passenger it Q Generator Q Outdoor <br /> ud L�� E-E_�.. 0 Q Closed Q Altered Q 0 <br /> GPS Latitude Hauler Indoor I <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) _ <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 Q 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 /> Q ! Q Notice Of Violation Q Extension <br /> Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date Q m / m <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 14`CCR_§-].$469.3--Retention of Comprehensive Trip Logs for 3 years <br /> i <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> ( � Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> 0 O Other: § <br /> Comments 1 <br /> t`' Jrl(:' <br /> }{n� <br /> E T <br /> Inspection Form Included: QII — -- _ - — --_ <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 IE X e A IV. <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />