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Waste Tire A.by & Inspection Reporo Inspection Report Number <br /> ■ - i3;u.S State of California " -------A- <br /> CIWMB181(New 04104) Survey Form - Page 1 , _-_ .1 0 13 <br /> California Integrated Waste Management Board -- - --- ----- ------- ------- - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> BusinessProfileInspection Details <br /> TPID- ' - � Inspection Type (Fill one) <br /> Site Suffix: 0 Q Routine O Re-inspection <br /> ection O Referral <br /> Observation <br /> Local ( If Referral,choose referral type(Fill one) <br /> Identifier: (.(ut �1(, (^ f li\ t. r' 1 "1 O CHP Q CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility me / -t <br /> ✓ Inspected By Inspector <br /> Physical Address I - FI-1 Tol <br /> Street <br /> f Inspection Date <br /> L <br /> City — e State ZIP Code Time In Time Out <br /> Business Rep Title <br /> �QAM 0 A <br /> QPM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all aha(° W' (Fill all that apply) (Fill all that apply)'. <br /> Tire`Count(Whole/PTE) <br /> a "I'll A3se <br /> ® Generator O O Itdoo <br /> rs(� Active rluretO Hauler O indoorLatitude O OClosed O <br /> 0 O Inactive O Trck "§', <br /> Longitude O Planned OTR <br /> OEnd-Use 0 Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O 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 /> O 0PRC <br /> Notice Of Violation O Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred I CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O O Other: <br /> Commentsl (Y <br /> rt �c Irt/ V©1+� <br /> Gt '� cft� 0; tea m t � -C {J 11 (,�►*d I, <br /> Inspection Form Included: Q <br /> Comments Included: O -- --'- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> / 62081 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X /,. !0 :' "6" r'1 (r 1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />