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ey F Ins ection 4 Reort Number <br /> L,131.23Waste Tire S & Inspection Repo pState of California <br /> CIWMB181(New 04104) Survey Form - Page 1 18 - 10 7 9 3 6 2 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A- Surve <br /> Business Profile fnspection Details <br /> TPID= , Inspection Type (Fill one) <br />} Site Suffix: t 0 Routine Q.Re-inspection Q Referral Q Observation' <br /> Local l"- If Referral,choose referral type(Fill one) <br /> Identifier: .�. 1_\ X ( [ `4 0 CHP. . Q CIWMB Q Complaint Q Educational Visit;Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address j <br /> Street r ` Inspection Date r 1 <br /> )) O 1A Time In Time Out t <br /> City ��tafe ZIP Code <br /> Business Rep Title 0 AM AM <br /> © (DPM F (DPM <br /> Operational Status Tire Type Business Role Storage Type <br /> 111J7 <br /> (Fill one only) (Fill all that apply) .(Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) y <br /> Q.Active Q Passenger Q Generator, Q Outdoor <br /> 0 O Closed Q Altered <br /> GPS Latitude, m • Q Hauler Indoor <br /> O Q Inactive 0 Truck <br /> Longitude – Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q 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 Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 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 /> 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 l Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q I 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 ® In Compliance - No Violations <br /> Q 0 Other: § -- <br /> Comments ..S�� �-----I--�=�--- <br /> 01- <br /> Inspection Form Included: Q' <br /> . ___ - .- _- _ ---- _ ..-.. . `.. .- -- _..Comments Included ,Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK . Correct: Incorrect: X V E X FA ij�i R1. I E 1112 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />