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section Report Number <br /> Waste Tire S, & Inspection Repor�n_ p p __ <br /> WM <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 � <br /> California Integrated Waste Management Board - _ -- -- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> 5pectralt Qet�lM'� n ---- -- <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local V If Referral,choose referral type(Fill one) <br /> Identifier: I 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> I <br /> Business or Facility Name I Inspected By Inspector <br /> i IPhysical Address – L—L <br /> Street l Ej] l EP]Inspection Date <br /> ! – odd I Time In El <br /> _ Time Out <br /> tarty State 11P Code Business Rep Title 0 AM 0 AM <br /> 0 PMLI] � 0 PM <br /> - Operational Status Business Role3tdrge Type ' <br /> (Fill one only) 'I M <br /> )t' (Fill all that apply) (Fall al!that apply) <br /> 0 Active 0 Passenger0 Generator 0 Outdoor <br /> 0 Closed 0 Ai- '-d <br /> GPS Latitude -` ==O <br /> Y 0 Hauler 0 Indoor <br /> O Inactive 0 Truck <br /> LongRude 0 Planned OTR 0 End-Use 0 Container <br /> Busme hype'• <br /> III;e1..h app y)' - <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 0 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> i <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 /> M / M / m <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 /> -- <br /> O O -- - <br /> 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 For Included 0 a "" <br /> jr <br /> cc ment Included 0 , <br /> Bdslness Rep s Signature Phone <br /> `Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:is Incorrect: .ne �/ P L '� <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� ■ <br />