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Waste Tire furve & Inspection Report Inspection Report Number <br /> . state of Callfornla y s p <br /> CRNMB181(New04104) Survey Form - Page 1 { 4 - 1 0 2 5 8 1 7 <br /> California Integrated Waste Management Board <br /> Part A.- Survey BLUE OR BLACK-INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- DInspection Type (Fill one) <br /> Site Suffix: 3 �7 - 1 ®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 /> i <br /> Business or Facility Name <br /> �D Inspected By Inspector <br /> Ph�jsical �a� <br /> 1nsp>scttt..1 Dpte I 0 A I � <br /> 3 <br /> V T104N Time Out <br /> Business Rep Title O AM O AM <br /> fit.fJ+1n'l j` O PM O PM <br /> I/i O �l.'W� Operational Status 1 Tire Type I Business Role Storage Type <br /> (Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PT t t <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> 0 ® Inactive Q Truck <br /> Longitude - Q Planned Q OTR O 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 O Other <br /> Part B - Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> _ r <br /> V I•. A HAULING AND MANIFEST REQUIREMENTS Q Notice of Violation Q Extonttofi< <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires y <br /> Q I O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O 1 PRC§42956-Registration/Decal in Vehicle s <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements I Data J / 3 <br /> 14 CCR§18459.1 a b c -Tire Program ID Number from CIWMB <br /> 010 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days I (Required for NQV 4T <br /> O ! O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ^ res 3` <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Rafsrrgd/CtwMS Erifet�aftinr�� ' <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use FacilitiesIC <br /> O i O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O I Other: § <br /> Comments l b �( ti b r"C_ Yet lJ <br /> �,(. Fta (L�.l.A t,•C.- ��'�,Q ��1 �, al,,t,•"V""' 1 r 't t 14- S fj7cow <br /> Crl- <br /> Inspection Form Included: QComments Included: Q Busin6s;Rep's Signature Phone Number Inspecignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:*- Incorrect: , E X a M P In I�31 s2ot31 <br /> While Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA <br />