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Waste Tire Su ey & Inspection Report Inspection Report Number <br /> StateofCalifornia Survey Form - Page 1 I 1 - 1141265 <br /> CIWMB 181(New nage) Y g <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: 5 V 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: n� CC.) 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name v t Inspected By Inspector <br /> Physical Address <br /> l L 3�7 �_S. <br /> Inspection Date <br /> v v O Time In Time Out lJ l <br /> Business Rep Title f O AM , Q AM <br /> PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ®Active 0 Passenger ® Generator 0 Outdoor <br /> O 0Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O o Inactive 0 Truck <br /> Longitude — o Planned 0 OTR 0 End-Use 0 Container <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 /> o Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other FICA"f I�LL�� <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ` ENFORCEMENT STATUS <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires J 0 Notice Of Violation 0 Extension <br /> o 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> o 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB i <br /> o 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> o 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 <br /> in Compliance - No Violations <br /> 0 0 Other: § - - -- <br /> Comments R /-S <br /> --- 1� � <br /> 7;;; <br /> Included: 0 0�©� <br /> Included: — <br /> -- <br /> Business Rep's Signature Phone Number In a r' Si ature Phone Number <br /> _-p_.T 62081 <br /> INSTRUCTIONS ON BACK �Gorrec �Incorrect1l►4 P I 2 3 <br /> White Copy:CIVVMB Yellow Copy:Operator Pink Copy.LEA <br />