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= Waste Tire Sur.,,:y & Inspection Report Inspection Report Number ■ <br /> '.. State California Survey Form - Page 1 7 - 4 3 5 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> 10 <br /> Part A--Survey_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: uC, 1 a , Routine ® Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP- 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Phji ai a,aa e - <br /> C Inspection Date ` ` / ` Z <br /> Time In Time Out <br /> Business Rep Title _ O AM _ O AM <br /> ttv\a"C r{_v V C Z 7 75 0 PM C l > ® 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 ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude I ® Hauler Q Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR ® 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 /> ------- <br /> Part <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 0 Extension <br /> ® 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 i Date <br /> 00 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB Mi F\�I F, I <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities __ - <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § -- ------ <br /> Comments - - - -- -- <br /> 11�--► <br /> C5 LkA/1 <br /> Inspection Form Included: 0 � �/ <br /> Comments Included: 0 4in.,pp <br /> Business Rep's Signature Phone Number _ tor's Signature _ _ _ Phone Number <br /> l 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X l, E X R !�, P j 2 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />