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5� Waste Tire Su&y & Inspection Reporf�inspection Report Number <br /> ' State of California <br />' bus Survey Form Page 1 1 1 X 006- 50 <br /> 0 <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- II _� i Inspection Type (Fill one) <br />} Site Suffix: I / @ Routine Q Re-inspection Q Referral Q Observation f <br /> Local If Referral,choose referral type(Fill one) - <br /> Identifier: — —_— 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> 1 Business or Facility Name i Inspected By Inspector <br /> X11 mPhysical Address <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> ]p AM <br /> m • m 0PM <br /> II i I R! i Operational Status Tire Type Business Role Storage Type <br /> I� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> Ll f I l f +, <br /> Q Active 0 Passenger Q Generator 0 Outdoor <br /> mO Q Closed 0.Altered <br /> PSLatitudeG <br /> Q Hauler 0 Indoor <br /> O Q Inactive 0 Truck <br /> Longitude – o Planned 0 OTR End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 0 Dismantler Q Tire Derived Fuel J <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> z; <br /> Part B - Inspection of Waste Tire Dealer, Generator Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS - <br /> Q Notice Of Violation Q Extension <br /> 0 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O , 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 ; Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O . Q i 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O ; Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years - - -- -.. ...-..-- <br /> Q I Q 00 14 CCR <br /> 1 § 0� Manifest q togeTire Haulers oReferred ClWMB Enforcement <br /> 14 CCR§18461Manifest System Rquirementsfor Waste Te End-Use Facilities. <br /> O I Q 1 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ar In Compliance - No Violations <br /> Q Q !Other: § <br /> Comments ` <br /> —.2 r <br /> Inspection Form Included: 0 <br /> Comments Includedi <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> u, 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E� .Aj F E r <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />