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eeu <br /> Waste Tire Su, .%,y:& Inspection Repor'L Inspection Report Number <br /> State ClWM f 81(New Survey Form - Page 1 L I3 - 10 7 9 3 4 1 <br /> CIWMB 181(New 04!04) � Y <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: t O I O ' I I O ( ®Routine Q Re-inspection Q Referral Q Observation <br /> Local /� If Referral,choose referral type(Fill one) <br /> Identifier: Su{ ) J Qct, ��n W W Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> L__ _Busines or Facility Name -- <br /> Inspected By Inspector <br /> � _ �. �Cel.c�_s <br /> Physical Ad ress <br /> Street E�] / / <br /> Inspection Date <br /> city Q� tate ZIP Code Time In Time Out <br /> Business Rep Title 0 AM AD AM <br /> lull <br /> I J 0 PM F 0 PM <br /> --- - Operational Status Tire Type Business Role Storage Type <br /> I <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � + � � ; � i <br /> ® Active Q Passenger Generator Outdoor <br /> -10 <br /> Latitude I I Q Closed Q Altered <br /> 1 JJ . L —I_ Q Hauler Q Indoor <br /> GPS <br /> F- <br /> _—L <br /> —_I___ 0 Q Inactive ®Truck <br /> Longitude - I I I - I I _J Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) JJJ���JJJ <br /> Q New Tire Dealer Q Auto Repair S 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 I I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> Q , Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 - Responsible Entities Complying with Manifesting Requirements Date <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 F>CT) <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/C-IWMB 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 ® In Compliance - No Violations <br /> Q Q Other: § on o <br /> Comments 1 ��M„�+ (� I �1 /� I <br /> ;- <br /> �'fc. c c b_���Ser�I ca..a 1S�i5 _osv� �r �1}5 aU — - <br /> Inspection Form Included: Q 01 <br /> Comments Included: Q &Ws <br /> ��usiness Rep' ature Phone Number InSignature Phone Number <br /> h� � <br /> INSTRUCTIONS ON BACKl',�,Drr�,ec�.�inco�rrect-.��� E X AP LE :2 3 62081 1 <br /> White opy:CI M Yellow Copy:Operator Pink Copy:LEA ® - <br />