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Inspection Report Number <br /> Waste Tire �ey & Inspection Rep �- p p � <br /> State California Survey Form - Page 1 $ - $ Q a <br /> CIWMBB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> BusinessProfile Inspection Details - - <br /> TPID-. !! �' z: r - FInspection Type (Fill one) _ <br /> Site Suffix: 4 q Routine Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: r<f Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> (Physical Address <br /> Street -T^� <br /> Inspection Date <br /> L <br /> co State ZIP Code Time In Time Out <br /> Business Rep Title (I 0 AM 0-AM <br /> QPM QPM <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(WhoMe/PTE) <br /> Active Q Passenger Q Generator Q Outdoor <br /> MW ML I <br /> Latitude 0 Q Closed 0 Altered <br /> ('jPs Q Hauler Q Indoor <br /> Q Inactive Q Truck: <br /> Longitude - Q Planned Q OTR Q End-Use Q 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 /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I <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 Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> 0 0 Other: § - <br /> Comments I r —T <br /> Ir <br /> ;f i r •I �, i c'ti -• ,n r�{F V _ I.[ ,-'� .1 , i r 1'�.c-}•k� _ _ — �-,' .. . <br /> Inspection Form Included: Q <br /> Comments Included: Q --- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> X 62081 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />