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s <br /> Waste Tire SuW ection Re& Inspection Report p port Number <br /> State of California <br /> CIWMB181(New 04104) Survey Form - Page 1 i 4 - � U1 3 5 16 <br /> I <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> � Inspection Details <br /> TPID- _ Inspection Type (Fill one) <br /> Site <br /> Site Suffix: �„ �' � "� � ' � 0 Routine Q Re-inspection 0 Referral 0 Observation <br /> Local ��"` �_ If Referral,choose referral type(Fill one) <br /> Identifier: t ( CHP CIWMB Complaint Educational Visit Other <br /> P <br /> Business orri Facility Name Inspected By Inspector <br /> Physical AddressEl <br /> J <br /> Street <br /> Inspection Date -, •, / [_! `- <br /> Cityp Title State Zip Code Time In �� O AM Time Out . <br /> Business Re 0 AM <br /> / —1 : F <br /> 0P 0 P <br /> Operational Status Tire Type � Business Role Storage Type <br /> (Fill one only) (Fill all that appCy), (Fill all that apply) (Fill all that apply) <br /> r <br /> e; Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude ,���, 0 Hauler 0 Indoor <br /> Inactive Trd " <br /> C 0 End-Use 0 Container <br /> Longitude — Planned OTR <br /> BiLlsiness 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 /> (a 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 m / mM <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 /> § P 9 Y <br /> 0 0 14 CCR 18459.3-Retention of Manifest Forms and Tire Tri Logs for 3 ears <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred r CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments , <br /> 77 <br /> f <br /> Inspection Form Included: 0 71N <br /> Comments Included: 0 -- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct:10 Incorrect: X �,°, E' 1 <br /> - <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />