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i:. Waste Tire Survey & Inspection Report Inspection Report Number <br /> its <br /> State of California <br /> CIWMB181(Now 04/041 Survey Form - Page 1 1 Z - 10 2 5 617 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection` � _ � � Inspection Type (Flit one) <br /> Site Suffix: j 3 ` 14) Routine Q Re-inspection Q Referral Q Observation <br /> Local ��• If Referral,choose referral type(Fill one) <br /> Identifier: 1 ,•�„ti,. � ��� I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> r J <br /> f Business or Facility Name <br /> Inspected By inspector <br /> +Physical <br /> -7oca14r-ey Pcir��=y <br /> l I Inspection Date <br /> �C.•-�P G/� �5�3c1 I <br /> I Time in Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Operational Status I Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill aft that apply) (Fill all that apply) (Fit?all that apply) <br /> Q Active 1 Q Passenger Q Generator Q Outdoor <br /> O I ® Closed Q Altered <br /> GPS latitude � Q Hauler Q Indoor <br /> • <br /> O I Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <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 I ENFORCEMENT STATUS <br /> • V A HAULING AND MANIFEST REQUIREMENTS I 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 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 <br /> / <br /> Q Q 14 CCR§16459.1 (a)(b)(c)-Tire Program ID Number from CIWMB / IT] <br /> Q Q 114 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days I (Required for NOV or OM <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 : 4 Referred/CIWMB Enforcement <br /> Q O 114 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Faciflties <br /> -.. _ - -- <br /> Q IQ 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators I I In Complienos No Violations <br /> 10 0 Other: § <br /> Comments 'rjU t t Y'e- ��►'- I'S' CJ7v��-—G'7` /1 1`S �rI TG /aiX�-t'Y/^(`� <br /> --tib a -t �a'f` T ►y"�- Y o. r- L�y e� i,,--L;lb +f v-- ul. <br /> Inspection Form :ncluded; Q q <br /> Comments ncluded: Q. � <br /> Business Rep's Signature Phone Number Ins r s Signature Phone Number <br /> INSTRUCTIONS ON BACK Carred InaorreatS t �1� i 11 rZ 3� 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />