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Waste Tire Surrey & Inspection Report nspection Report Number <br /> Stata8181of fNow Survey Form - Page 1 1 3 - 10 2 5 8 7 3 <br /> CIWMB 181(New 041D41 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> }Business Profile Inspection Details <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: tJ �, Q Routine ® Re-inspection Q Referral Q Observation <br /> Local 1 �-^'� If Referral,choose referral type(Fill one) <br /> Identifier: ; � 1� /'�t� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` it Inspected By Inspector <br /> I' <br /> /fln-e- 8� Iders <br /> Physics ddress l CSL� <br /> Inspection Date o —3 I 7 Ca <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � T <br /> • Active Q Passenger 0 Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude — Q Planned ® OTR Q End-Use 119 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ®Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station t® 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�, ' A' HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <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 /> PRC§42956-Registration/Decal in Vehicle rn m <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements pate <br /> Q O 14 CCR§ 18459.1 (a)(b) (c)-Tire Program (D Number from CIWMB ) ) I I 1 t <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXE <br /> 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> I <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Re?�rr9d;l,CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ' <br /> in CampTlance No Violations. I <br /> Q1Q § <br /> Other: <br /> Comments <br /> 7 b Z 0 el Z 2-57 S r <br /> A) I-J x15._ <br /> J__ <br /> Inspection Form Included: Q r' <br /> Comments Included: Q <br /> Elfisiness Rep's Signature Phone Number In s Signa a Phone Number <br /> to <br /> INSTRUCTIONS ON BACK Correct: II7��rre #; ( y, , i t_ 1 s2oa1 <br /> _ tel.' .:._._.__ �_._..... ._.� .I. . 1 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA K <br />