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Will. <br /> Waste Tire SL*ey & Inspection Repo'r- inspection Report Number <br /> State of California Survey Form - Page 1 I , - 10112 . <br /> CIWMB 181(New 04104) <br /> California Intfgrated 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: Q Routine Q Re-inspection Q Referral Q Observation <br /> Local f Referral,choose referral type(Fill one) <br /> Identifier: iQ t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street _ Inspection _J / 1 / ► <br /> r' ection Date <br /> I <br /> City State ZIP Code Time In Time Out 0 AM <br /> Business Rep Title � AM <br /> }_ memo m mm 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ❑f �f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I Q Active Q Passenger Q Generator Q Outdoor <br /> 0 1 Q Closed Q Altered <br /> GPS Latitude m . I Q Hauler Q Indoor <br /> O ® Inactive ) Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q 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 ( Other Sehiolc t_,✓� f r,�{.f <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - ................ <br /> . <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - - -- - - - Q Notice Of Violation Q Extension <br /> Q <br /> Q PRC§42951 -Waste.Tire Hauler Registration and Transport of Tires <br /> Q Q 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 IE m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB . <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I 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 ®,In Compliance - No Violations <br /> ,0', Q Other .§ <br /> Commentst, (U1 <br /> L/' �r � Y• „:. 1�..)r7 !, ✓ <br /> hca tiC( a! /v/C:_ s t,' lIbal wo j0,61 e: C�: ��wl '�rno✓ t <br /> (4, a C- �_3 ) tnO�J j__N1_L0 6 f I Q L-6c t — <br /> Inspection Form Included Q`; <br /> Comments Included 0' - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:01 Incorrect: I EIXI.AIMI P It I El I 112] 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® S <br />� s - <br />