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€ 1_ Waste Tire Survey & Inspection Report Inspection Report Number _ <br /> Im State B California Survey Form Page 1EI1 - 1108456 <br /> CIWMB181(New nage Y _ <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details -� <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: �� �I �' I 3 S I O I Routine Re-inspection Referral Observation <br /> 711 <br /> Local / ` If Referral,choose referral type(Fill one) <br /> Identifier: [�1�/n _ _ ( _ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name S� <br /> Inspected By Inspector <br /> Phys al res <br /> �3 <br /> Sheet <br /> =,/Z � Inspection Date <br /> City T .�p.KD f�vA,��t Time In VVV_ Time Out <br /> City �- 5tateL;P C _ _ _ <br /> Business Rep Title i �II , I I 0 AM <br /> 10AM <br /> ®.PM <br /> 10 i ® 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 /> f ® Active ® Passenger 0 Generator 0 Outdoor <br /> Latitude O 0 Closed 0 Altered <br /> GPS 0 Hauler 0 Indoor <br /> � � - ----- 0 Inactive ®Truck <br /> -- O <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ®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 f <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire,Hauler Registration and Transport of Tires O Notice Of Violation 0 Extension <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 m / 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 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 ®In Compliance - No Violations <br /> 0 1 0 1 Other: § <br /> Comments ' � s <br /> Inspection Form :nc <br /> ncluded: 0 <br /> Comments luded: <br /> Busine Rep's Signature r Phone Number Inspector's a Pure" Phone Number <br /> INSTRUCTIONS ON BACK Cor ct: ncorrect: j ( R A M P L E 1 2 3 62081 <br /> White Copy: IWM Yellow Copy:Operator Pink Copy:LEA <br />