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Waste Tire Sura ,y & Inspection Report inspection Report Number <br /> State <br /> CIWMB <br /> 181(New <br /> Survey Form - Page 1 - Z $ 4 �� <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 Inspection Type (Fill one) <br /> Site Suffix: L 3I I b— (* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: _.,�t 4- <br /> 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date ( ` I / ,---1- <br /> State ZIP Code Time-11-n— Time Out <br /> Business Rep Title 0 AM i 0 AM <br /> 0 PM 1 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r=, ' (0 Active Q Passenger Q Generator Q Outdoor <br /> O QClosed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> IL 1Longitude Q End-Use Q ContainerI\ Q Planned Q OTR <br /> . <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet QGo rnment Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Colle''on Q Crumb Rubber <br /> Q Service Statiork Q Hauler Q Agriculture Q Shredd Q Other <br /> Part B - Inspec 'on of Waste Tire Dealer, Generator, Hauler an End-Use Facility ENFORCEMENT STATUS <br /> V ! A HAULINq AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§429 1 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§4295 Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956 ~Registration/Decal in Vehicle <br /> Q Q 14 CCR§1845 Responsible Entities Complying with Manifesting Requirement Date <br /> Q Q 14 CCR§18459. `(a)(b)(c)-Tire Program ID Number from CIWMB M / m / m <br /> Q Q 14 CCR§18459.2.\ Submittal of Manifest Forms and Tire Trip Logs within 90 da (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-14Vention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Maritfest System Requirements for Registered Waste Tire HaulersQ Referred/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifes�System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest ystem Requirements for Tire Dealers or Waste Tire Generators `' _ Q In Compliance - No Violations <br /> Q O Other: § <br /> Comments <br /> --� � �'—�_-� •� 1 �.� _ w - _- '''�`- _fit <br /> Inspection Form Included: Q <br /> Commentsncluded: Q <br /> I :~Business Rep's Signature Phone Number Inspector's Signatur Phone Number <br /> � � � � <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � � � �+. ,V. 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />