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i <br /> Inspection Report Number <br /> THE Waste Tire Suay & Inspection Report. ■ <br /> -nr, <br /> Ea EGF State of California <br /> CIWMB181(New 04104) Survey Form - Page 1 9 10 1. 0 7 4 0 <br /> California Integrated Wasle.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: - © (E) Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: loo-C/ coo y Q CHP Q CIWMB Q Complaint Q Educational Visit .Q Other <br /> Business or Facility Name 71 <br /> T Inspected By Inspector <br /> id� <br /> Physical Address _ <br /> / I �,+ <br /> Street [OM <br /> j� �`�Qj^ Inspection Date�(" V 7 <br /> �`fi • � 1 Time In Time Out <br /> city State ZIP Code <br /> Business Rep Title . O AM O AM <br /> Iwo m • �0PM m • m ® 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 /> L_L—LJ (0 Active Passenger Q Generator (D, <br /> O I Q Closed 0 Altered <br /> GPS Latitude m • � Q Hauler Q: Indoor <br /> O Q Inactive Q Truck <br /> Longitude - FFF I T-1 Q Planned Q OTR (5 End-Use 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 /> a , <br /> Q Service Station Q Hauler Q Agriculture Q Shredder (b Other <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 /> Q 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 1.Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 /> 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/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 Q Other: § f <br /> Comments <br /> QC4 1 14 ,t �. T�� r''e�t �Cil j;l� �r1cCI S of _!/itlt' 1l �rG` (Ltz> 7� <br /> � r <br /> 14 �C r0 � � rc�fQlt :�0k QnC.. C� �< . <br /> Inspection Form Included'' <br /> Comments Included. ........... <br /> Business Rep's Si nature Phone Number Inspector's Signature Phone Number <br /> -� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ) i� E'1 #jM "' :� � 1 .�' ;� <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />