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lit: Waste Tire Su&y & Inspection Repor" Inspection Report Number <br /> State of 181(Now <br /> Survey Form Page 9 1 3 - 1 01 4892 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile J Inspection Details <br /> TPID- � -3 � � � � � _ b / Inspection Type (Fill one) <br /> Site Suffix: • Routine Q Re-inspection Q Referral Q Observation <br /> Local �.. If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 'vJ Inspected By Inspector <br /> Physical Address <br /> Q <br /> Inspection Date C> � / "7 �' � 0 S <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> Q PM O PM <br /> Operational StatusTire 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) Z <br /> f I® Active Passenger Generator ®Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> o Q Inactive ®Truck <br /> Longitude — ® OTR Q End Use Q Container <br /> Q Planned <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 /> Q Service Station Q Hauler ®Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS ^ <br /> V A HAULING AND MANIFEST REQUIREMENTS .Q Notice Of Violatlon Q Extettslph <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle m <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m l ( 4 <br /> Q O 14 CCR§18459.1 (a)(b) (c) -Tire Program ID Number from CIWMB <br /> O O (Requ,r+ea!far NOiI qr y <br /> �14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 RIIA0.+4d(CI(IVIiAS <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities 3 <br /> O O �� <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators "WO" <br /> O O I Other: § _ /Q <br /> Comments I �Gtf�it ' �!G!'rr, _ <br /> Jr.. <br /> 1 32. 9 L-M S— b j <br /> 'Inspection Form Included: Q _ <br /> Comments Included: Q <br /> S s ss Rep's Si na re Phone Number Ins is Signature Phone Number <br /> _..62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAMP L f 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />