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Waste Tire Su vey & Inspection Report Inspection Report Number <br /> -•r��� State of California <br /> CIWMB 181(New D4l04) Survey Form ' Paye 1 1 8 - 1 0 0 6 6 6 6 <br /> Califomia Integrated Waste Management Board _ <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile �n Inspection Details —_ <br /> TPID- � Z � � ` I <br /> — —�� Inspection Type (Pili one) <br /> Site Suffix: i t7 � 0 --* 0 Routine Q Re-inspection ® Referral. Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> ,0CpI.L.M Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> AA _ _ p Y Inspector <br /> Physical Address Y` <br /> Street M <br /> Inspection Date <br /> L_Lo &t __ cz <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM [� <br /> Q AM <br /> Qa PM ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I ! 1 L I C> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 0 Active ® Passenger ®Generator Q Outdoor <br /> 1 �{ O 0Closed 0 Altered <br /> GPS Latitude U , I I� Q Hauler Q Indoor <br /> o 0 Inactive 0 Truck <br /> Longitude — i I I ,i I I � 1 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) l <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 I I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS_ <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m / m <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB ED <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EX'!) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 ® 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities —_ <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> 0.1 0 1 Other: § <br /> Comments <br /> Inspection Form Included: 0 �\ <br /> Comments Included: QA�1n_sVc_1Vr**s <br /> Business Rep's Signature Phone Number Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: jEjXjAjMjPjLjEj 1112 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />