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Waste Tire Survey & Inspection Report Inspection Report Number <br /> ■. State of California17 <br /> CIWMB181(Now 04104) Survey Form - Page 1 1 6 - 10 2 5 8 2 r <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> Inspection Type (Fill one) <br /> Ste Suffix; 3 3 3 , c 1 '* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: +0 CHP QCIWMB Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name` Inspected By Inspector <br /> t� Dit"J,C-C D l o VV-<5 r---+ - <br /> Physical Address Q , �y �v/j "Vxq"'k <br /> E <br /> VA WJI'e� <br /> Inspection Date tj I ,u I L3 <br /> Time In Time Out <br /> Business Rep Title) / O AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ^ „` (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> `~ 0 <br /> 0 Active (10 Passenger ®Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> C) Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR 0 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 { J <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ' ENFORCE_ ENTSTATUS <br /> Y.'I A H ..AI)LIN ND f>i 4 IFIST_ OUIREMENT8 <br /> Q Q Q Notice Of Violation Q Extatsiott <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> o ® PRC§42953-Contracts with Registered Waste Tire Haulers. i Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> 0 ® 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data <br /> FF <br /> 0 Q 14 CCR§18459.1 (a)(b)(c)-Tire Program iD Number from CIWMB <br /> Q ! Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Req for NOV or 6X7) <br /> Q 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred CIWMB Enfotpmeflt <br /> 00 , <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: § Ip Gomp actor• No violatlena <br /> --- ( _E__ - <br /> Comments �t - � 1 �tc��(► \ ��C.�} ���-- �.I�yVP,>S_c•L �w� Y'� �' <br /> C �ru_ L tUAr P <br /> t <br /> ON L <br /> Inspection Form Included: l t 7� -- <br /> JComments Included: Q <br /> usiness Rep's Si a Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Q t` t� X A M P � ( �, 62081 <br /> . White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA <br />