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■ � i, .3■ <br /> SoWaste Tire Suzy & Inspection..Report r�nspection.Report Number <br /> aeStateof BCalifornia Survey Form - Page 1 a 3 - 0 3 3 2 1' <br /> + <br /> CIWMB 181(New nage) Y <br />� California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br />'SBusiness Profile Inspection Details <br /> TPID �, - r Inspection Type (Fill one) <br /> I Site Suffix: 3 Cj (} ) j�. �. r (11 Routine Q Re-inspection Q Referral Q Observation <br /> Local / / } If Referral,choose referral type(Fill one) <br /> Identifier: �" �1 �dr3 4q..1� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ( �� Inspected By v Inspector <br /> Physical Address Com. I �� 0 C <br /> Street <br /> ( , Inspection Date <br /> Time Out <br /> City State ZIP Code Time In_- �, <br /> Business Rep Title ` (5 AM / f 0 AM <br /> 1 m <br /> " �. L 0 PM <br /> 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE)Q Q�i t (/ r> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f J !J T7 ( Q Active Passenger (9 Generator @ Outdoor <br /> Latitude m • O Q Closed 0 Altered <br /> GPS Q Hauler Q Indoor <br /> 0 Q Inactive Q'Truck <br /> Longitude - Q Planned Q;OTR Q End-Use Q Container <br /> I <br /> Business Type (Fill all that apply) <br /> Q^New Tire Dealer ®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 f <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 /> - <br /> p Y - -------- --- -- --- -- --- --- <br /> V ' A HAULING AND MANIFEST REQUIREMENTS <br /> - -— Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transportof 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 m / 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 /> Q 1 Q 1 Other: § <br /> Comments <br /> 01(" Cc I t{ '.i( �/'� �- ( t�� Gtf' '(1' p r (,t c( <br /> " I <br /> ;( fLC <br /> /1 <br /> Inspection Form Included: Q <br /> Comments Included - <br /> Business Re s ignature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EX 'MI P I I El I 12 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> ■ <br />