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-- -- ----------- <br /> ni. <br /> Waste Tire Survey.& Inspection.Report Inspection Report Number ■ <br /> $rWMS 181Cali(No- Survey Form - Page 1 1 1 8 -_ 1.41 3 0 6 5 <br /> CNYMB 1Bt(New 041041 <br /> California Integrated waata Management Board <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details 0634TD-HM <br /> TPID- 1 � � J� f^: `;, � - � J Inspection Type (Fill one) <br /> I Site Suffix: I ( CYC `T ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: \01 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Add►ess <br /> a_I N1 ( ckee- I - <br /> Street &i <br /> Inspection Date <br /> �� <br /> � — <br /> ty J State ZIP Code Time In Time Out <br /> mBusiness Rep Title 0 AM 0 AM <br /> m O PM 'lel 0 PM <br /> VL <br /> AOM mrnar� <br /> _ __ � _J Operational Status The Type Business Role Storage Type { <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 3 5Ip <br /> ®Active ®Passenger ®Generator !Outdoor <br /> 1 D Q Closed Q Altered <br /> GPS Latitude 4 Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - I ! ` Q Planned Q OTR Q End-Use Q 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 Q Hauler Q Agriculture Q Shredder Q Other _._l <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 FF] <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / m / m <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 EXT) <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 t CMWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q Q Other: § I jf <br /> Comments k <br /> _o— <br /> Z _�eSf_ <br /> Inspection Form Included:Q a <br /> Comments Included: -�G -�0)�. - _;_S <br /> Business Rep's Signature Phone Number Insp- is Slg at re Phone Number <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect:�)( 9 E X a M P E 2 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy Operator Pink Copy LEA ® ■ <br />