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E:. <br /> Waste Tire Softy & Inspection ReportInSpection Report Number ■ <br /> Sate of California I j _ `� I I <br /> �'� CIWMB 181(New04104) Survey Form - Page 1 - _ <br /> I �? = 3 a <br /> California Integrated Waste Management Board <br /> Part A- Survey r — BLUE OR BLACK INK PEN <br /> f Business Profile Inspection Details <br /> El. <br /> TPID- L_,J <br /> Inspection Type (Fill one) <br /> Site Suffix: E)I. , l (? Routine Q Re-inspection Q Referral Q Observation <br /> Local ��� / If Referral,choose referral type(Fill one) <br /> Identifier: I /1 r^ ) { Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> -------------- <br /> Business or Facility Name Inspected By Inspector <br /> I _ <br /> Physical Address (� - f"� C '�✓` `` < ��'f `, <br /> _ I <br /> � { <br /> Street ( r r <br /> Inspection Date <br /> --- - I -- - State ZIP CodeTime In Time Out <br /> T <br /> . Business Rep Title 0 AM L _J � AM <br /> O PM _ O PM <br /> - IOpera LTi -,FB us <br /> Operational Status re Type iness Role Storage Type <br /> Ttre Cdunt(Whole/PTE) , <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)': <br /> st Active Q Passenger Q Generator Q Outdoor <br /> tl _ O `1 Q Closed Q Altered <br /> I Q Hauler Q Indoor <br /> GPS Latitude �0 Q Inactive Q Truck <br /> Longitude - „ , 1TT' Q Planned Q OTR <br /> 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 <br /> Part B - Inspection of Waste-Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Q <br /> - - - - _ -- Notice Of Violation - 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. I Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle i <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O <br /> 14 CCR§ 18459.3-Retention of Comprehensive 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 /> QQ (Other: § -_._._ ._,_.._. . . ......__.._ .,,.,_......... ...._ .._._.___F_..__ <br /> Comments <br /> s 1 ._ !1',t /1, <br /> - <br /> i � r <br /> 44 <br /> Inspection Form Included: <br /> Comments Included: <br /> :Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> / e 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X I- \, / A ���1 �. <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />