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sNumber <br /> • <br /> Was _Waste Tire Su & Inspection Repor p e_ction_Report_State of California <br /> �;; CIWMB 181(New 04/04) Survey Form - Page 1 a 1 3 - 10061, 00 '` <br /> Calrfornia Integrated Waste Management Board - <br /> Part A- Survey <br /> - . ajM v ^ <br /> '" ryBLUE^ORt` BLACK <br /> ' I'N, K PEN <br /> p <br /> e '711 u"M - �° <br /> Business Profilp <br /> TPID <br /> - Inspection Type (Fill one) <br />{ Site Suffix: `� _ (2) Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��.__-. /`� r r'_; ,r( ; 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name r <br /> Inspected By Inspector <br /> y -- �` <br /> Ph slcal Address � •^� / C -` - � ,.-: - <br /> st`—ier .. _ <br /> Inspection Date y <br /> City State ZIP Code Time In Time Out <br /> _ ems. <br /> Business Rep Title ( 0 AM 0 AM <br /> � • OPM 0 P <br /> r LL FM Operational Status Tire Type. Business Role `Storage, s <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all tha �`�. <br /> A=A Active Passenger Generator 0 Outda"I r <br /> f4 ra <br /> ® "R <br /> 0 Closed 0 Altered <br /> Gps Latitude , 0 Hauler 0 Indoor <br /> r tW <br /> -�_ 0 Inactive 0 Truck <br /> T7,Longitude <br /> 0 End Use 0 containerOPlanned 0 OTR <br /> � <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 <br /> 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 _ 0 Notice Of Violation 0 Extension <br /> 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 M / 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 § System Requirements for Waste Tire End-Use Facilities _ <br /> 14 CCR 18461 -Man fest S st <br /> 14 CCR§18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q ' 0 0 In Compliance - No Violations <br /> 0 0 Other <br /> Comments <br /> 1 <br /> , <br /> n <br /> Inspection Form Included: 0 y, <br /> Comments Included: 0 _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> f 62081 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X <br /> ® White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ?© ■ <br />