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r€I�o <br /> Waste Tire Su010 & Inspection Report"Peetion Report Number <br /> State of California <br /> a I - 1127872 <br /> CIWM8181(New <br /> Manage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey_ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � Inspection Type (Fill one) <br /> �Site Suffix: ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral.choose referral type(Fill one) <br /> Identifier: Se 10 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> .�� <br /> ZLSCOw I rvC iV>0 % <br /> Physical Address <br /> Inspection Date <br /> S fL� fL N" L A %�_Z/S <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> / PM V /C © Q 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE} 7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I*Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 <br /> Q Notice Of Violation O Extension <br /> 0 O 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 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 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 1 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 ® in Compliance - No Violations <br /> Q Q Other: § <br /> Comments ` <br /> Inspection Form Included: Q / )r' <br /> Comments Included: ® Z67�—o6 Z3 <br /> _ Bus ss Rep's gnatur Phone Number or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON ACK Correct: Incorrect: X f' X1 A, IMI E f �R <br /> WhiteiCopy:CIWMB Yellow Copy.Operator Pink tW�o <br />