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' 091.82050025 <br /> Inspection Report Number <br /> Waste Tire SL ey &- Inspection Repo <br /> Stateof California <br /> CIWMB181(New04f04) - Survey Form - Page .1. 15 - 10 7 9 3 6 $ 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- b <br /> Inspection Type (Fill one)Site Suffix: � I V Routine Q Re inspection Q Referral Q Observation <br /> j 311, ]- <br /> Local If Referral,choose referral type(Fill one) <br /> �(�Identifier: _` j�J{,yM n_+n=j Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �� �- Inspected By Inspector <br /> Physical Address <br /> Street � <br /> 5 Inspection Date <br /> PA <br /> City State ZIP Code 65 �J Time In Time Out <br /> L <br /> Business Rep Title [::X <br /> f� 0 AM 0 AM <br /> 0 PM O ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> • Active ® Passenger • Generator ® Outdoor <br /> O Q Closed Q Altered <br /> Latitude <br /> l <br /> O Q Hauler Q indoorGPS Q Inactive Q Truck <br /> Longitude - I ! I I i Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 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 I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> � Notice Of Violation Q Extension <br /> Q <br /> 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 DateM� <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB l <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 /> 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 Q In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> Inspection Form Included: Q of /�Q �j/,, <br /> Comments Included: 0 — - -(�7 - - 2��`^j—�v <br /> Busine4ReSloature I Phone Number Insp c r gn ture Phone Number <br /> �-�( Xf 62081 <br /> INSTRUCTIONS ON BACK Cor ect: correct: VX <br /> ( �J E X A M P L E 1112 3 <br /> White Co :CIW Yellow Copy Operator Pink Copy.LEA <br />