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� J-Waste <br /> Tire Suy & Inspection Repor�Inspection._ _ Report Num <br /> b-er <br /> CIW <br /> State of California <br /> � <br /> MB 181 VALe <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> �. <br /> Part A Surve BLUE OR BLACK INK PEN <br /> TPID- 4 _ _ ,_� j Inspection Type(Fill one) <br /> Site Suffix: Q Routine 0 Re-inspection 0 Referral Q Observation <br /> Local ? If Referral,choose referral type(Fill one) <br /> Identifier: j <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical _ I <br /> Y s <br /> Street Inspection Date 1 <br /> – Time In Time Out <br /> city �– State Z/f'Code 111 : EE <br /> Business Rep Title O AMQPM P 0 <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that appl (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whale/PTE) <br /> ii 10 ailli: !1111 0 Active 0 Passenger,,' 0 Generator 0 Outdoor <br /> , , LLJLatitude — Closed Altered <br /> IGp$ l Q Hauler 0 indoor <br /> p ® Inactive 0 Truck <br /> Longitude – 0 Planned 0 OTR 0 End Use 0 Container <br /> Business`hype (Fill all that 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 i A j 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 <br /> M / m / 7 <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 /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 0 In Compliance - No Violations <br /> 0 0 Other: <br /> Comments <br /> Inspection Form Included: 0, <br /> Comments Included: - - - <br /> 0 Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X �; I &. ,0y`i .. 110117 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />