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nspection Report Number <br /> Waste Tire Su. - _y & Inspection Report <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 - 10 0 6 1 14 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 Inspection Type (Fill one) <br /> Site Suffix: �" 1 V ` Q Routine (jo Re-inspection Q Referral f Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: S CA,t, , ooh 0(.i l� I Lo 1.114" Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility—Name `\I 1 Inspected By Inspector <br /> Physical Address ISrV �-e� l <br /> Inspection Date q\ � ` Dt � C> 5 <br /> Time In Time Out <br /> Business Rep Title , *AM O AM <br /> O PM Z b 5 ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ® Passenger Generator Q Outdoor <br /> � D Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude – Q End-Use ® Container <br /> Q Planned Q OTR <br /> I _ <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 Q Hauler Q Agriculture Q Shredder Q Other <br /> --- ��.—. –--- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 1 A HAULING AND MANIFEST REQUIREMENTS <br /> _ <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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or FJC� <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 I# 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> O 0 Other: § - <br /> Comments M(fit rc,,V. 1ti9 � T kTf D i t -- <br /> 1 t r 0`` W I.ct,� Crol � L� <br /> � � - O f 1 V��t <br /> Inspection Form Included: <br /> Comments Included: Q <br /> siness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> —_ -- 62081 <br /> INSTRUCTIONS ON BACK Correct:_ Incorrect: jE'XjAIMjPJL1E1 1112 3 <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA <br />