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� <br /> Waste Tire Suuuuuuuuy & Inspection Repor ,. InspectionReportNumber; . <br /> State of California <br /> WOMI, <br /> � <br /> IW <br /> CMB181(New 04./04) Survey Form - Page 1 Il - 1108466' <br /> California.Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details r <br /> } TPID- T . _ m Inspection Type (Fill one) <br /> Site'Suffix: <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: lit } �(� 1(� �� <br /> �'C.. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> - Inspected By Inspector <br /> Physical Address <br /> iL -V <br /> Street <br /> Inspection Date <br /> city State ZIP Code I Time In Time Out <br /> City <br /> Business Rep Title Q AM 0 AM <br /> EMe� PM 14@PM <br /> f Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I - (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> h I Q Active Passenger Q Generator @ Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m • T] Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> -------- ------ <br /> - <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler. Q Tire Derived Fuel <br /> 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ! A !HAULING AND MANIFEST REQUIREMENTS <br /> ! <br /> Q I Q �PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <br /> Q 10 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 ® � V E <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> r Q 14.CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-"Manifest-System Requirements for Registered Waste Tire Haulers Q Referred/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 i <br /> � __ �,,�,,")t:< , ► Cts . f" <br />} <br /> Inspection Form Included: Q' <br />: <br /> Comments Included Q - <br /> Business Rep's Signature Phone Number Inspector's Signature I Phone Number <br /> � 62081 <br /> • INSTRUCTIONS ON BACK- '; Correct:* Incorrect: X) � d �, ,A ,h�'t �' � �' � �- 3 <br /> White. . -- - — ---- --. <br /> ■ Copy:GWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> ll" . v •I <br />