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Waste Tire Sur. .y & Inspection Report Inspection Report Number <br /> State of California Survey Form - Page 1 1 3 - 1 0 2 8 3 2 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 0 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 <br /> Inspected By Inspector <br /> Physical Address <br /> dk— <br /> Inspection Date U C js 5� <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ,11� <br /> / O PM O PM <br /> c.c,uti�.cZzril f7`'`' <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 /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive ® Truck <br /> Longitude - 0 End Use Container <br /> 0 Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 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 /> ® Notice Of Violation 0 Extension <br /> I® 0 PRC§42951 -Waste Tire Ha..er Registration and Transport of Tires <br /> ;0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956- Registratiol in Vehicle <br /> ® 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB 1 <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 /> 0 014 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 /> Ci.,l' , Oil(GL -,L`9,,c, <br /> _�< (4( & - &V <br /> t,> �-5 v.�^^.� o <br /> Lo f <br /> Inspection Form Included: 0 <br /> Comments Included: Q <br /> si s Rep's Signature Phone Number Insp tit.' Signature Phone Number <br /> �--j- 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ,. E Xi R 1�� 3 <br /> V.��-Copy CIW t"1B Yellow Copy:Operator Pink Copy LEA <br />