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Waste Tire Survey & Inspection Report Inspectid% M0W <br /> suite of California <br /> ClWMB181(N w Survey Form - Page 1 1 2 - 1 0 1 9 4 7 2 <br /> cNYMB 181(New 0*/l!4) Y <br /> callromla Integrated Wast*Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> - <br /> TPID- m Inspection Type (Fill one) <br /> Site Suffix: ` L `� t 3 O ( ®Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �CrM l r Q CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> Physical Address I141 / - / �2 I <br /> Sqoe <br /> 'soa(it <br /> Inspection Date <br /> ocl�+w.— -_ Gt q s -o(o <br /> C'ry Stale ZIP Code Time In Time Out <br /> Business Rep Title :0-1 O0 AM PM F—U LI OOAM <br /> PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' r O Active O Passenger O Generator O Outdoor <br /> O Closed O Altered <br /> GPS Latitude O Hauler Q Indoor <br /> i.--j ® Inactive O Truck <br /> Longitude ' i 1 O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet Q Government O Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station Q Hauler ®Agriculture Q Shredder Q Other I <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> O O Q Notice Of Violation Q 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-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> Q O (Other: § <br /> Comments <br /> L, �vcl/�I�2—Glv�-�30f�ta�ta��tz.s'.�/o_�IZ-UJ�c.-r�./,�a_r,,c' --�l•Sc-rvro�[-rte -- <br /> _Jrn4-C.f✓-Y-tt.�.u—�fr(.G-- <br /> Inspection Form Included: QI <br /> Comments Included:Q — <br /> _ Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect: (� E X A M P L E 62081 <br /> 1 2 3 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />