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■ <br /> Waite Tire Surep p inspection Report Number <br /> & Ins Inspection Report � <br /> State of California I > �`i - F g5 <br /> * � CIWMB 181(New 04104) Survey Form - Page 1 _- 14 E ' <br /> I `jt <br /> California Integrated Waste Management Board <br /> Part A Survey BLUE OR BLACK INK PEN <br /> nspecv, <br /> TPID- Inspection Type (Fill one) { <br /> 1 - E F I <br /> I _ <br /> Site Suffix: _ 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ^ If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address I — ! 1 <br /> Street <br /> Inspection Date <br /> State ZIP Code Time In L Time Out _ <br /> Business Rep Title 0 AM 0 AM <br /> DPM i . I 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 /> Tire Count (Whole/PTE) <br /> ! 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude <br /> O 0 Closed 0 Altered <br /> GPS R 0 Hauler 0 Indoor <br /> 0 Inactive O.Truck <br /> Longitude , 0 Planned 0 01-R 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 IA HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 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 FP / M / F7 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 1 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 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 Form Included: 0 <br /> Comments Included: 0:: <br /> Business Rep's Signature Phone Number Ins ect_o_r's Signature a Phone Numberer <br /> 62081. <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: ' ]A l l P 1.I l-i 1 a 2 , 3 i <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� ■ <br />