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Waste Tire SLAY & Inspection Reporter <br /> Inspection Repork Number <br /> State of California <br /> for CIWMB 181(New04104) Survey Form - Page 1 I 1 1108476 <br /> California Integrated Waste Management Board -... - <br /> Part A- Survey - _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> --- <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: <br /> r � r_:� Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: r <br /> _ j r s�t�•'L•(,r �� r ( � 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> J <br /> Physical Address ���/ ; t 42 <br /> 1 <br /> Street <br /> r ; Inspection Date <br /> Ir <br /> ci+v t State Z/P Code Time In Time Out <br /> Q AM <br /> Business Rep Title i l AM 0 PM / 0 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 /> ' Q Active Q Passenger Q Generator 0 Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude _ 1 Q Q <br /> � Hauler Indoor <br /> _._� –7 F__-..__7—_T—r O <br /> 0 Inactive Q Truck <br /> Longitude – Q Planned Q QTR 0 End Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader Q Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> Q Service Station 0 Hauler 0 Agriculture Q Shredder 0 Other <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 Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / m m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q 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 Q In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments - <br /> j � , r <br /> 17 A <br /> .r <br /> W"l s_a /v A( <br /> Inspection Form Included: Q <br /> Comments Included: Q w, <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> s 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �/ p 2 31 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />