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■ Ec E{ Waste Tire S ey & Inspection Repo Inspection Report Number, ■ <br /> . ii. State of California <br /> SurveyForm - Page 1 1 8 - 1025779 <br /> CIWMB 181(New 04104) <br /> California Integrated 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: FT 1 `l1. r I = - ` Q Routine Q Re-inspection Q Referral Q Observation j <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB O Complaint Q Educational Visit Q Other <br /> Business or Facility Name kl�l 1,C,-7—I _. <br /> , Inspected By Inspector , <br /> Physical Address <br /> Street Inspection Date <br /> City State% ZIP Code I Time In Time Out J <br /> Business Rep Title 0 AM O AM <br /> � • mI ,- <br /> 0 P 0 P <br /> j I Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �::M (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply} <br /> -- G) Active Q Passenger Q Generator 0 Outdoor I <br /> O Q Closed 0 Altered <br /> GPS Latitude m • Q Hauler 0 Indoor <br /> O O Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use Container <br /> Business Type (Fill all that apply) <br /> 10 New Tire Dealer O Auto Repair O Trucking.Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body �0 Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station Q Hauler :Q Agriculture Q Shredder Q Other /VA <br /> Part B - Inspection of Waste-Tire Dealer, Generator, Hauler and End-Use Facility i ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation Q Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. i Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> (Required for NOV or EXT) <br /> 0 O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 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 /> 0 Q 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> 0 i 0 ;Other: § <br /> Comments <br /> nspection Form Included: <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I', Correct:0 Incorrect: �' (� 'Tt 62081 <br /> 3 <br /> J■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />