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jMWaste Tire Survey & Inspection Report Inspection Report NumberStets B 181(Ne la ' Survey Form - Page .1 1 3 - 1 0 7 3 3 4 4 <br /> CIWMB 181 Waste <br /> ew'eaee) <br /> Callfomla Integrated Waste Management Board - <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I <br /> nspectionInspection Type (Fill one) <br /> Site Suffz: 1 ,31019 11 O U ®Routine O Re-inspection O Referral O Observation <br /> Local If Referral;choose referral type(Fill one) <br /> Identifier: L � T _ O CHP O CIWMB O Complaint O Educational Visit O Other, <br /> Business or Facility Name Inspected By Inspector <br /> PhysicaT Address <br /> Street 7 <br /> (� C q5, L/ O Inspection Date I U <br /> A l o r <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> ,' <br /> m'm0PM LLI '� 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> J (Fill one only) (Fill all that apply) (Fill all that apply) .(Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ®Active O Passenger ®Generator Outdoor <br /> PS Latitude _J O Closed O Altered O <br /> IndoorGH I-L_J-10O Olnactive ®TruckO Hauler <br /> Longitude =.[ O Planned O OTR O,End-Use O Container. <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair_ O Trucking Fleet S Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other — <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING ANDMANIFEST REQUIREMENTS <br /> --- ------------ Q Notice Of Violation O Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O' PRC§42956-Registration/Decal in Vehicle <br /> O' O ,14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required far NOV or EXT) <br /> O O - - ---- <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/ - MB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> O 10 1 Other: § <br /> Comments Mmv_m, dAte . <br /> l' �+ <br /> KjC .,Feo!- _FVfF"s N e1.4J <br /> O Vifl } <br /> Inspection Form Included:O <br /> Comments Included-O _ __ 331-717-9- U <br /> Lhs Rep.'s Signature Phone Number'. In ignaturePhoneANumber <br /> INSTRUCTIONS ON C Correet:� Incorrect: E X Ifi4 P L E 4 ,2 3 62081 <br /> ■ While Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® '. <br /> I <br />