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vo1 �1v•v+>>so <br /> Waste Tire Survey& Inspection Report Inspection Report Number ■ <br /> Stato of California <br /> ° <br /> CIWMB 181(New Survey Form Page 1 I 1 1 0 7 9 3 0 7 <br /> California Integted Waste Management ment Board <br /> j Part A-Surye BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection D Inspection Type (Fill one) <br /> Site Suffix: 7 R]t .Routine Q Re-inspection Q Referral Q Observation {, <br /> Local If Referral,choose referral type(Fill one) - <br /> Identifier: OQ�C(w1r Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> r--, Inspected By Inspector <br /> Physical Address _F I <br /> F/ FO /I <br /> Street /V/ p <br /> Inspection Date 0 9 � � •� � � g <br /> City State ZIP Code Time In ( Time Out <br /> Business <br /> pRep <br /> � Title jyf <br /> [&?]� / D 0 PM � � � O 0 PM <br /> Operational Status Tire 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) <br /> r I ° ! i40 Active ®Passenger 0 Generator •Outdoor <br /> — I <br /> GPS Latitude ,I_•._I_L-- I O Q Closed Q Altered Q Hauler Q Indoor <br /> I � <br /> O Q Inactive ®Truck <br /> Longitude — 1 � I I,I I I I� Q Planned ®OTR Q End-Use Q Container <br /> Business Type-(Fill all that apply) <br /> ���JJJ II <br /> Q New Tire Dealer . Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler ®Agriculture Q Shredder Q Other t I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violatio Q Extension <br /> Q Q PRC§42953-Contracts with.Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Require /or NOV or F>CT) <br /> 14 CCR§18459.3•Retention of Comprehensive Trip Logs for 3 years <br /> Q Q '14 CCR§18460.2.Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 C-IWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q Q 1 Other: §, <br /> Comments <br /> Ni e.vey 70 <br /> inspection Form Included: <br /> Comments Included:0, <br /> Business Rep's Signatureone Number Inspector's Signature Phone Number <br /> _ _ <br /> INSTRUCTIONS ON-BACK- �urrect:� Incorrect: [jIX A M P `� E' 1112:131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LFA <br />