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imWasteTire Su; ey & Inspection Repor' Inspection Report Number <br /> State B California Survey Form - Page 1 I 1 - 1141288 <br /> CIWMB 181(New 04104) y ry <br /> California Integrated Waste Management Board y <br /> Part A- Survey_- _ _-_---_-__- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection/ t Inspection Type (Fill one) <br /> Site Suffix: `-ll 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: � ��`� Caws Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or FacilityName <br /> \ \ Inspected By Inspector <br /> Physical Address <br /> 2� Inspection Date <br /> C� Q5Z3C� l <br /> Time In Time Out <br /> Business Rep Title f . 0 0? AM �*'� Q AM <br /> 31UL�/) �( 1 ® PM <br /> -- - -- - - - - - Operational Status i Tire Type Business RoleStorage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that aPPIY) (Fill all that aPPIY) (Fill all that aPPIY) <br /> f ® Active Q Passenger a Generator ® Outdoor <br /> O Q Closed Q Altered I <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ll 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 Q Hauler Q Agriculture Q Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> - - - _ _._. <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 m m m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® In Compliance - No Violations <br /> Q Q Other: § - -- <br /> Comments e(��� \_< _ _ ( � - <br /> 1 , l Y l.J IY")-p�T7(.fes <br /> Inspection Form Included: Q <br /> Comments Included: Q — -- - -- --- —- ---- <br /> Bus! ess Rep's Signature Phone Number Ins ct r' S nature Phone Number <br /> INSTRUCTIONS ON BACK ox � t 62081 <br /> I �r �lx[A;,,m P 0 E 2 <br /> White Copy:CIWMB Yellow 0opy:Operator Pink Copy:LEA <br />