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. ii-A Waste Tire Sy & Inspection Repo inspection Report Number <br /> 6L6 State of California �} r9 ■ <br /> CIWM6181(New 04104) Survey Form - Page 1 0 _ J <br /> California Integrated Waste Management Board -_-- - -- <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> :Business Profile - ---- -- - - --- -- Inspection Details -- <br /> - Li 1-1 - LL_ Inspection Type (Fill one) <br /> Site { <br /> Site Suffix: Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �. Q CHP Q CIWMB Q Complaint •Q Educational Visit Q Other <br /> Business or Facility Name _ <br /> Inspected By Inspector <br /> i <br /> Physical Address <br /> EE L <br /> i <br /> Street <br /> . Inspection Date L'Y--�_..,..—.I / E <br /> _.,., <br /> State ZIP Cade Time In (Time Out <br /> Business Rep Title AM (5) AM <br /> � N 0 P 0 P <br /> 1 <br /> Op(Fierational <br /> only)lStatus Tire <br /> Type apply) - <br /> =. I Business Role ' Storage Type <br /> Tire Count (Whole/PTE) (Fill all that apply) (Fill all that apply) <br /> Q Active 0 Passenger Q Generator Q Outdoor <br /> O Q Closed` Q Altered ' <br /> Latitude i j � f Q Hauler Q Indoor <br /> GPS <br /> -1- Q Inactive Q Truck <br /> O <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> - r-....:- <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 6 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT-STATUS <br /> IV I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q 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 (Required for NOV or EXT) <br /> Q Q 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/CIWMB 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 Q In Compliance - No Violations <br /> Q Q Other: § - <br /> Comments <br /> Inspection Form Included: Q', <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> - _- 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X "v \/ - <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />