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I . <br /> Waste Tire Sdw & Inspection Repo nspection Report Number ■ <br /> "= I- State of California ' <br /> CIWM B 181(New 04104) Survey Form - Page 1 - 1 0 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business.;Profilei splbn`Lgpttls'r"J}.- — - . <br /> TPID- Inspection Type (Fill one) <br /> , <br /> Site Suffix: �a '1 ' } (a Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: / t i (�( �titr" ';;t f ..J :? Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> L?. VI ) <br /> Ph sicaI Address <br /> ! <br /> (DI-1 L-1 r�� C,, C.1 f t,, I r� <br /> Street � Inspection Date <br /> t r ( <br /> City State. ZIP Code Time In Time Out_ � ---. <br /> Business Rep Title O AM O AM <br /> OPM M <br /> � �_,_, �__ 0 P <br /> ky in ('t 1 f �t � tt I(tr J ► 7 - <br /> „r 3rF Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply)! (Fill all that apply) (Fill all that apply)' <br /> Tire CountWhole/PCE <br /> �� H Q Active Q Passenger J Q Generator Q Outdoor <br /> f PS Latitude O ® Closed Q Altered� I I , Q Hauler Q Indoor <br /> G <br /> Q Inactive Q Truck <br /> Longitude — ITTT I i i Q Planned Q OTR ,, Q End Use Q Container <br /> f <br /> Business Type (Fill all that apply) <br /> ON-ew 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 r A HAULING AND MANIFEST REQUIREMENTS _ Q Notice Of Violation Q Extension <br /> 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 <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> O Q Other: § <br /> Comments I f ► � { <br /> Inspection Form Included: Q <br /> Comments Included: 0 _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 620£31 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: :�;, a. ".1. P N-,i 1 L <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />