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Waste Tire Sul, - ay & Inspection Repors Inspection Report Number <br /> l.4. State of California <br /> at <br /> ClWM13 181(New 04/04) Survey Form - Page 1 1 8 - 1 0 0 6 6 7 1 <br /> California Integrated Waste Management Board <br /> Part A-_Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O � Inspection Type (Fill one) <br /> � <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local <br /> If Referral,choose referral type(Fill one) <br /> Identifier: ,SGL t 1� O CHP Q CIWMB O Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address`' O <br /> �1^ Inspection Date u L <br /> Time In Time Out <br /> Business Rep Title O AM _ O AM <br /> ' 4'PM PM <br /> f� J 3 ~L ®- - - - - <br /> I -V\ L� t> V V��''L <br /> - -- Operational Status' Tire Type Business Role i Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) f p <br /> ® Active ® Passenger ® Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - 0 Planned Q OTR ® End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government O Retreader Q Dismantler 0 Tire Derived Fuel <br /> I <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station ® Hauler 0 Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V j AHAULING AND MANIFEST REQUIREMENTS I <br /> Notice of Violation 0 Extension <br /> O ® PRC§42951 -Waste Tire Hauler Reqistration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / Fn <br /> O 1 O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O 0 III 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years l <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/.CIWMB Enforcement <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 In Compliance - No Violations <br /> O O Other: § <br /> Comments ��\�_ t`ti`�`?�CCsv�, WM,�,I.�(/�L t-v -y`L ��,tT�W4�.�.c�ly� �'►roK� 1- __ <br /> tC__ !i-L L 75 Gi�, OVA <br /> 5 _C <br /> c <br /> Inspection Form Included: <br /> Comments Included. <br /> usiness Rep's Signature Phone Number In pector's Signature Phone Number <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct Incorrect ry�yi , E XA M P L 1112 3 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />