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nspection Repan Number_" Waste Tire Survey ,&. Inspection Report I - <br /> i�r_ <br /> »= State of California <br /> CIWMB 181(New 04104) Survey Form' - Page 1 4 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business ProfilInspection Details <br /> TPID- a, Inspection Type (Fill one) <br /> Site Suffix: r Q Routine Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier c;d X11. �,,�„� G7y� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or F-aac-ilility Name Inspected By f Inspector <br /> Physical dress <br /> Street , Inspection Date Fo <br /> 6 �� Code Time In Time Out <br /> Title <br /> City State —ZIP IP Code _F <br /> Business Rep <br /> p AM O AM <br /> m m0PM F -1 OPM <br /> Operational Status Tire Type Business Role Storage Type <br /> 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) , <br /> Active ®Passenger Q Generator Q Outdoor <br /> 1 PS Latitude , ' � � D Q Closed Q Altered ® Hauler Q Indoor <br /> G <br /> _ Q Inactive Q Truck <br /> Longitude - I i I I I Q Planned Q OTR <br /> Q End-Use ® Container <br /> I i � <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 Hauler Q Agriculture Q Shredder Q Other I 1 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS_ _ <br /> HAULING AND MANIFEST REQUIREMENTS L <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953 Contracts with Registered Waste lire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle I <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> [T] <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB (Required for NOV or EXT) <br /> Q Q 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 O Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ -- <br /> 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 /> G'►-,r. -��, 1( , �G_�' i�uys��-��ln�,1_l—s T� <br /> Inspection Form Included:•Q <br /> Comments Included:® ---r`��fF`�` r <br /> Business Rep's Signature Phone Number In is Signature Phone Number <br /> ' ,-,/ 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: }(R3 v ! X A M P L 1 3 ® ■ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA r <br /> r� <br />