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Waste Tire Sut . ay & Inspection Report Inspection Report Number ■ <br /> CIWMB <br /> 181(New Survey Form - Page 1 I 1 - 1143748 <br /> California Integrated Waste Management Board Y <br /> Part A- _ BLUE OR BLACK INK PEN <br /> Survey- <br /> less Profile Inspection Details <br /> TPID- Inspection� � � _ C) Inspection Type (Fill one) <br /> Site Suffix: t 3 � 1 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local �w � J��,, / If Referral,choose referral type(Fill one) <br /> Identifier: `�1� ,> CW►L I (/� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or FacilityN - <br /> ame Inspected By Inspector <br /> JL�G <br /> Physical Address <br /> Inspection Date <br /> s � Via` <br /> Time In Time Out <br /> Business Rep Title �j ®AM AM <br /> �""� �+lviV2.11rit�i ( v O PM © � Q PM <br /> rl 1'�r tG�1 Cerxt+iL Aet lzb4_ - -- <br /> ------- ---- t'- - — 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 Q Outdoor <br /> O 0 Closed Q Altered Nils N/4 <br /> GPS Latitude Q Hauler Q Indoor <br /> �( <br /> O Q Inactive Q Truck�� <br /> Longitude - Q Planned Q OTR <br /> Q End-Use i Q Container <br /> i <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder OtherL} <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facilityf ENFORCEMENT STATUS <br /> V A <br /> Q HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> A � <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 m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> � <br /> Q 0 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 11 ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> �1­jpection Form Included: ®i �G,`,1 C_v' �- � r���� nature S- �Number <br /> Comments Included: <br /> Business Rep's Signatu Phone Number I e or' Phone Num <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: 7 + h�4 R j <br /> ■ _ - - --- ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />