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® Waste Tire Sury & Inspection Report nspection Report Number <br /> State of California <br /> c+% CIWMB181 <br /> Waste <br /> Survey Form - Page 1 <br /> 11014833 ' <br /> California Integrated Waste Management Board - V <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Ste Suffix: Inspection Type (Fill one)� _ <br /> W <br /> !� Routine (� Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 7- Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date / <br /> city State ZIP Code Ti_m__e_ In __ Time Out <br /> Business Rep Title _ 0 AM = : FT_ O AM <br /> el <br /> : _E—]0 PM 0 PM <br /> Operational Status Tire Type, ti Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> 9 9 t _� <br /> (Fill one only) (Fill all that apply] (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger °' Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude i + 0 Hauler 0 Indoor <br /> -A ./`-�—�-��O 0 Inactive 0 Truck <br /> Longitude - � � 0 PlannedO'R 0 End-Use 0 Container <br /> Business Type (Fol all thar apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date Ffl / M / M <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - _ - <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> - ! _ JCC <br />} L <br /> Inspection Form Included: 0' <br /> Cornments Included: 0 - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® incorrect: X r, th,% 7, 1: 62081 1 i <br /> li ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />