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® - Waste Tire Su4y & Inspection Reportlnspect►on Report Number <br /> State of California J, 1 <br /> - CIWMB181(New 04/04) Survey Form - Page 1 T 1 1127607 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business;Profile Inspection <br /> TPID € ;r/� l i Inspection Type (Fill one) <br /> Site Suffix 1 �/' t✓' i Q Routine Q Re inspection Q Referral Q Observation <br /> _ j. <br /> Local \ / If Referral,choose referral type(Fill one) <br /> Identifier: �,[\�!1 �✓��C ;'.�' ` �/ ( (j i Z Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 1 3 j <br /> Physi al 'Ad'd re ss <br /> L_ t l 1.61....:1. ...___.._ _� ..._..._.._._..... ..._....._...................... <br /> SPreef Inspection Date <br /> V_ : <br /> �.._ T _ Time Out <br /> State ZIP'Goo,; <br /> Time In �.. <br /> Business Rep Title O AM / O AM <br /> � PM � _ ! 0P <br /> R { LU � � � _ <br /> ). Ae - � 3i` ''�' � Operational at Tire Type Business Role Storagp Type <br /> (Fill one only) "(Fill all that apply)I (Fill all that apply) (hili all that apply) <br /> Tine Count(Wholelll'i g <br /> Q Active "'0 Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude I O Hauler O Indoor <br /> — <br /> D Q Inactive L Truck <br /> Longitude — E .m_.. I Q Planned 00 <br /> f Q End-Use Q Container <br /> .Business Type (Fill all that apply) <br /> .�. <br /> Q New 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 A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> -- -- <br /> Q Q 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 / m m <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOVr EXT) <br /> Q Q <br /> 14 CCR§18459:2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/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 /> 0 0 Other: § <br /> Comments �1L),il ltile \1� C j `�'Z C'Ck,I e Cal <br /> 'Inspection Form Included: Q <br /> Comments Included: Q ins e 'or <br /> c Business Rep's Signature Phone Number I 's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X Y A M i P <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />