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nspection Report Number <br /> Waste Tire SAW & inspection Report <br /> r Iilaf State of California - :� �'; r) r, '} <br /> CIWM6181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> 'art A- Survey- -- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local It Reterral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> _.._ Inspected By Inspector <br /> Physical Address <br /> Inspection Date + �� <br /> I <br /> Time In Time Out <br /> Business Rep Title { O AM { , i 0 AM <br /> Q PM I 1 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 /> Tire Count (Whole/PTE) <br /> Active 0 Passenger 0 Generator Outdoor <br /> I" 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> I <br /> 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR End-Use 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 A HAULING AND MANIFESY REQUIREMEN'rS - 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / FTI <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 /> 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 n <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature - Phone Number <br /> INSTRUCTIONS ON BACK Lorrect:0 Incorrect: X 7, V 01 I E XI A'MI P I L I EI 11 121 31 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� <br />