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4 Waste Tire Su y & Inspection Repor ' Inspection Report Number ■ <br /> State of California N <br /> CIWMB 181(New04/04) Survey Form - Page 1 - 10 0 6 4 9 <br /> California Integrated Waste Management Board _ <br /> Part A- Survey BLUE OR BLACK INK PEN \ <br /> l y ,�,di"� <br /> Business Profile . ;Inspection .'( �r. �� <br />} fl <br /> TPID- E <br /> - !Inspection Type (Fill one) <br /> Site Suffix: 1 �•Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 - If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility^Name Inspected By Inspector <br /> Physical Address J ` L l '• ,1 r, ; <br /> -- <br /> Inspection Date EE <br /> J <br /> -- —� - c ) I Time In Time Out <br /> State 7_!P Cvde __ <br /> Business Rep Title O PM ---- - O AM <br /> i <br /> 0 PM <br /> 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude -� Q • Q Hauler Q Indoor <br /> ��JJ O Q Inactive Q Truck <br /> Longitude - - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (s=ill all that apply) <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 I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <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 Q <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 /> - <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 /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: Q' <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> . _ 62081 <br /> INSTRUCTIONS ON BACK CorrectV Incorrect: X 1;, !a r;l A V. o' l,- 1 , 2 �m <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� ■ <br />