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Waste Tire Suloby & Inspection Repor" .nspection Report Number <br /> s=aa State B 181(New 04/04)California <br /> CIWMB Survey Form - Page 1 1 0 - 1 0 2 8 8 8 2 .1 <br /> California Integrated Waste Management Board <br /> art A- Survey BLUE OR BLACK INK PE <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> I Site Suffix: I Z 16 -7 1 I I I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local1-- I If Referral,choose referral type(Fill one) <br /> Identifier: '--- �( r t E A//j'Ih/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Street <br /> / n q Inspection Date ® / ► r— O S- <br /> C,7V State ZIP Code Time In Time Out <br /> Business Rep Title O AM I I . I I O AM <br /> 0P QPM <br /> :� ��` _ <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE (Fill one <br /> only) (Fill all <br /> that PP apply) (Fill all that apply) (Fill all that apply) <br /> Q g (a Generator O Outdoor <br /> dl ou, All!ff171 ,' d ild i)1,11 <br /> Latitude Q Closed O Altered <br /> IG PS' Latitude Hauler 0 Indoor <br /> l Q Inactive Truck <br /> Longitude — Q Planned ,Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) i <br /> O New Tire Dealer O Auto Repair Q Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder 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 /> - - � Notice Of Violation � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O O Other: § <br /> Comments -7 <br /> 7 -- <br /> r <br /> vJ11 `--i'zf- <br /> /5 <br /> f 1 J <br /> Inspection Form Included: <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's S,i�natuFe �u Phone Number <br /> INSTRUCTIONS ON BACK Correct:• incorrect: X E X1 A MI P I L I EI 11 l 2 13 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> t <br />