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i== Waste Tire Su %.y & Inspection Report Inspection Report Number <br /> Cei Survey Form - Page 1 1 6 - 1 41 4 7 8 6 <br /> State of California <br /> CIWMB 101(New 04104) <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: (� Cl/ (� ( ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localy��� If Referral,choose referral type(Fill one) <br /> Identifier: C> � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical A s <br /> Inspection Date / � � f ,I O s <br /> 1 <br /> Time In Time Out <br /> Business Rep Title Q AM - Q AM <br /> QPM QPM <br /> pto56'%d V_ 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 /> 7 40 Active 0 Passenger &Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> D 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 (� Extensiorf <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadllne <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 . 0 14 CCR§ 18459 - Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 : 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required forNOV vriX7� 1 <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years T <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred f Cl1NMf3 Enforoetstiif;t <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities Y` <br /> -- <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> fJ 1 Inir4 Nth <br /> 'ther: §0 0 O <br /> Comments <br /> ( a 2-7 �; � ,,,.� r ��► I`'1( 1'5`9 9 22-5- , 4111-AelP <br /> inspection Form Included: 0; g <br /> Comments Included: 0 � ` <br /> Busine Reps Signature Phone Number I c or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ( j l C A M1 P ILIE t 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA <br />