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Inspection Report Number <br /> Waste Tire Su&y & Inspection Report ■ <br /> :9E35-� State California <br /> CIWMBB 181(New 04104) -Survey Form Page 1 ` 0_ 6 I <br /> �➢5�E6 -- ., „- <br /> California Integrated Waste Management Board "_---- <br /> Part A Survey BLUE OR BLACK INK PEN <br /> Bustftes�,QrAf)a Inspection Details <br /> u _ Inspection Type (Fill one) <br /> TPID- <br /> Site Suffix: <br /> ! _) 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 Inspected By Inspector <br /> Physical Address .J L <br /> Street Inspection Date ::� � <br /> 1 r <br /> )9 <br /> State ZIP Code Time In� 0 AM Time Out O AM <br /> Business Rep Title m <br /> PM <br /> s. QPM 0 <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(Whole/PTEA <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> p <br /> Q Closed Q Altered <br /> GPS Latitude O Q Hauler Q Indoor <br /> !� Q Inactive a Truck <br /> Longitude — Planned Q OTR Q End-Use Q Container <br /> 11' <br /> Business Type (Fill all thai 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 Notice Of Violation Q Extension <br /> Q j 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 Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I 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 /> Q Q Other: § _- <br /> Comments <br /> Inspection Form Included: Q Zp� � � 7 <br /> Comments Included: Q' - Inspector's Signature Phone Number <br /> Business Rep's Signature Phone Numberp g <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X =' <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy.LEA <br />