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Waste Tire Sui .:y & Inspection Report Inspection Report Number <br /> elft State of California <br /> CIWMB181 <br /> Waste <br /> eManag ) Survey Form - Page 1 I 1 - 1140819 <br /> California Integrated Waste Management Board <br /> P- II A- Survey _--- - -- BLUE OR BLACK INK PEN <br /> less Profile j Inspection Details <br /> ,J- Inspection�- _ Inspection Type (Fill one) <br /> Site Suffix: ! / S Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sa+l 7V4 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Busness or FaciityNameJ <br /> — <br /> Z Inspected By Inspector <br /> Physical-Address <br /> I <br /> 3 Y-O 6k" e knl <br /> Inspection Date <br /> Time In Time Out <br /> j Business Rep Title O AM Q AM <br /> d0 ® PM Oz 0 ® PM <br /> -— Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) �j (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 ® Closed Q Altered <br /> GPS Latitude i Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR 1 Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 9w Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> sed 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 /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q 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 In Compliance - No Violations <br /> Q 1 Q Other: § <br /> Comments <br /> L2 ��sr�e✓� <br /> Ir, Aion Form Included: Q <br /> Comments Included: . <br /> l fv a <br /> Business Rep's Signature Phone/Number Inspector's Signature Phone Number <br /> X ` _--_�-� �� 62081 <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: � � f E X A Jhlk P �. � � � � <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />