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s Re ectiori ort Number <br /> ■ Waste Tire Suy & Inspection Repor p <br /> State of Survey Form - Page 1 <br /> CIWMBB181(New 04/04) 1 0 13 11 16 <br /> California Integrated Waste Management Board <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- j Inspection Type (Fill one) <br />'} Site Suffix: CJ' ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local -^ If Referral,choose referral type(Fill one) <br /> Identifier: �I 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> •Business or Facility Name - <br /> Inspected By Inspector <br /> Physical ddress <br /> [4 <br /> Street _J <br /> Inspection Date Ell <br /> , ;t <br /> City T State Z/P Code Time In _ Time Out 0 AM <br /> Business Rep TitleO0 AM [ i� <br /> PM O PM <br /> w L Operational Status Tir �� �� Business Role Storage Type <br /> e <br /> (Fill one only) (Fill � (Fill all that apply) (Fill all that apply) <br /> 0 Active Q 0 Generator 0 Outdoor <br /> p <br /> EE ® Closed 0Latitude ,Alfa Gln <br /> GPS t 0 Hauler 0 Indoor <br /> I]= <br /> �� �D 0 IInactive 0Tr, ( fit° <br /> Longitude _ 0 Planned 00 <br /> 0 End Use 0 Container <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 /> 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 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice Of Violation 0 Extension <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 / 71 / 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/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 __... - - --------------------- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> -- 62081 <br /> INSTRUCTIONS ON BACK Correct:4D Incorrect: X �, IF� ,a, ��i l i j <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> i <br />