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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California I t'} l U ' 4 f 1 4 <br /> -�==m CIWMB181(New 04104) Survey Form - Page 1 v <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN_ <br /> Part A- Survey_- <br /> In Details <br /> Business Profile <br /> - — Inspection Type (Fill one) <br /> TPID- _ <br /> Site Suffix: .Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C CHP Q CIWMB Q Complaint Q Educa:c-al Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address l \ <br /> ` [ �, _ Inspection Date U <br /> l� Time In Time Out <br /> � A?.1 0 A <br /> Business Rep Title <br /> 0 P%l O PM <br /> Cperational Status Tire Type Business Role Storage Type <br /> q - one only) (Fill all th 'at apply) (Fill a� mat (Fill all that apply) <br /> Tire Count (Whole/PTE) f OActive Q Passenger Q Gerara <br /> Latitude ':- ® Outdoor--- <br /> Closed Q Altered <br /> Q Hz�ler Q Indoor <br /> GPS � Inactive Q TruckQ End-U__ Q <br /> O Container <br /> Longitude – Planned Q OTR <br /> Business Type (Fill all that apply) <br /> O <br /> --t Retreader Q D smantler Q Tire Derived Fuel <br /> Q New Tire Dealer Q Auto Repair Q Truck ng Fleet Q Governr <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collecticr. Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other '��^ J� ,�� sk-N'rr� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> by '��1Gk HAUEJNGAN MANIEE . QUIREM S' QNotice Of Violation; <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O ® PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956 Registration/Decal in Entities <br /> Vehicle El <br /> Q O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date 11 II tl <br /> O ® 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWIMS <br /> (Required for NOV or EXT) <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O 0 <br /> ItzefercedCtY1fY <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other. § <br /> Comments D N W ky�� CL�� N,,� fin) <br /> �"�-�� M.4�`'� `f✓1�o,�.. 1 D W I,�1,t-T rlK ��-C�y�-y� �ry� a� U�C.c�,S�� C- <br /> •, <br /> Inspection Form Included: Q <br /> Comments Included: Q Busl ep� Signature Phone Number Ins ctor's Sign ure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON ACK Correct: Incorrect: X E k A, — <br /> Wh:� Yellow Cc., - -ra;or Rnk C�c> <br />