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Waste Tire Joey & Inspection Rep( Inspection Report Number <br /> State of California <br /> CIWMB 181 04/04) <br /> I 1 — 112 7 7 5 0 <br /> California Integrated Was eeManagement Board Survey Form - Page 1 <br /> Part A- Survey_- -__ ___- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: <br /> 33 ` ' • Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier. ` ` Cw'► l -- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> S <br /> W, con <br /> Physical Address C� l 0 ` <br /> ij <br /> C Inspection Date 1 Z <br /> `-s�� � c\ q��6)6' Time In l Time Out! �! <br /> Business Rep rt Title i 0 AM AM <br /> 14 �� ` r. l �� t 0 PM �— �_ 0 PM <br /> �hc, M&K - <br /> -- - -- n Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) �/J <br /> Active Q Passenger ® Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use 1 Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 ENFORCEMENT STATUS <br /> V i A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 <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 /> 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 ) !� <br /> i <br /> All L_" J <br /> Inspection Form Included: <br /> �{ �f r <br /> Comments Included: - - - - - - --- - - --- - - <br /> Btt ' ess Rep ignature Phone Number Ins c gnatur Phone Number <br /> INSTRUCTIONS N BACK Correct Incorrect 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pin Cop ■ <br />