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Waste Tire Sy & Inspection Repo r inspection Repot Number <br /> ■ <br /> Wig <br /> State of California _I -. ry 4 "S <br /> CIWMB 181(New 04/04) Survey Form - Page 1 t ;^`_ .., E <br /> California Integrated Waste Management Board <br /> urvey _ BLUE OR BLACK INK PEN <br /> Part A S <br /> r b�" <br /> �" <br /> Inspection Type (Fill one) <br /> Q0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ; ( 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> { <br /> f _ <br /> Inspection Date <br /> Street <br /> Ins p ElEd <br /> 1 <br /> ----- Time In Time Out <br /> Cii,y� S'ta(e �ZPP Cocle� ---_..._..__.. [T-_ <br /> _ . <br /> Business Rep Title O O AM <br /> O PM � . O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> r/ (Fill one only) (Fill all that apply)', (Fill all that apply) (Fill all that apply)NNNIEE ' <br /> ® Active 0 Passenger 0 Generator 0 Outdoor <br /> _ — _^ D 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude - + , p 0 Planned 0 OTR <br /> 0 End-Use 0 Container <br /> __ <br /> s,Mness Type (Fill all tt1 t ap,k <br /> 0 New Tire Dealer 0 Auto Repair ® 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 /> ene <br /> I HAULING AND MANIFEST REQUIREMENTS - <br /> - - --- - - -- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility - ORCEMENT STATUS <br /> Y ENF <br /> V A 0 Notice Of Violation 0 Extension <br /> 0 0 I 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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: 0, <br /> Comments Included: 0,•=Business <br /> ness Rep's Signature Phone Number Inspector's Signature:_ Phone Number I <br /> - L Z 62081 <br /> INSTRUCTIONS ON BACK Correct: incorrect: 'x ILf,+ A 3 <br /> M�P, L E� <br /> ;.;;■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />