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Waste Tire SL ey & Inspection Repor, Inspection Report Number <br /> State ClWM 181(New Survey Form - Page 1 j -10 10 6 3 51 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile nspection Details <br /> TPID- ? Inspection Type (Fill one) <br /> oSite Suffix: I , / �F �� / & Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local j If Referral,choose referral type(Fill one) <br /> Identifier: ) (yt lk.ir A. 1 \ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ! ' ( f <br /> � `Iy Inspected By Inspector <br /> i/� <br /> _ <br /> Physical Address <br /> _ t Ir i i <br /> Street <br /> Inspection Date 2 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title AM O AM <br /> m : F] 0PM 0 P <br /> _J I <br /> Operational Status ire Type Business Role ,orage`Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply <br /> Tire Count (Whole/• ) ill all that apply) <br /> �j <br /> ® Active 0 Passenger 0 Generator Outdoor <br /> O 0 Closed 0 Altered <br /> GPS I FTI <br /> Latitude m d O i 0 Inactive 0 Truck 0 Hauler 0 Indoor <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> ar <br /> Business i7will all that ap <br /> 0 New Tire Dealer 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 IT / m / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <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 /> 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 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments � <br /> {ltU't. t+ i � f; (( UJ I'I G ad.aA e —J-it UJ�y`� n t� � ,t S <br /> tkj0 C nn iwl� r� <br />- i <br /> Inspection Form In%luded':, <br /> Comments Included: 0 - - - - <br /> Business Rep's Signature Phone Number Inspector's Siggature Phone Number <br /> 62021 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X iC A NI P LJEJ It 12[3]' <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA,. <br />