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Wasle Tire Sur y & Inspection Report inspection ReportiJurraber ■ <br /> Nate of California a <br /> >i>; Survey Form i - 1 00634 <br /> "* CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: +� r �' O Routine (D..Re-inspection Q Referral0 Observation. <br /> Local ., If Referral,choose referral type(Fill one) <br /> Identifier: �" ` " O CHP Q CIWMB O Complaint O Educational Visit Q Other <br /> Business or Facility Name !� Inspected B <br /> P Y Inspector <br /> Physical Address <br /> Street _ <br /> Inspection Date <br /> City State Z!P Code Time In Time Out <br /> Business Rep Title _ Q AM c Q AM <br /> l� ® PM. © J ( 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 /> Active Passenger (&Generator Outdoor �I <br /> D Q Closed C)'.-Altered <br /> GPS Latitude m • @'Hauler Q Indoor <br /> D Q Inactive 0 Truck <br /> Longitude — O Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer 0 Auto Repair Q Trucking Fleet 0 Government Q Retreader 0 Dismantler O Tire Derived Fuel <br /> �3 Used Tire Dealer Q Auto Body Q Car Dealer, Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder 0 Other I I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> ..... --...... <br /> .... ---- <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation 0 Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date LI] <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days • (Required for NOV or EXT) <br /> 0 O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years - -- - <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred!CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q In Compliance - No Violations <br /> 0 1 Q 1 Other: § <br /> Comments yV'� ) <br /> c, e�*14�G Pj <br /> inspection Form Included: 0'1 <br /> Comments Included: . ..... .. <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct.* Incorrect: ;� Ej .A, Pj.0Ej 11 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />