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073120404ili <br /> ne <br /> Waste Tire Survey.&..Inspection Report- Inspection Report Number. . <br /> State of California <br /> CIWM8181steManage) Survey Form . Page-1 { 3 - 1 01 0 8.6 <br /> California Integrated Waste ManagemenfBoard <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 10 1 ®Routine Q'Re-inspection QReferral Q Observation <br /> rvation 1 <br /> Local [5��a If Referral,choose referral type(Fill one)Identifier: _Y1 O CHP QCIWMB Q.Complaint Q•Educational Visit QOther <br /> Business or Facility Name •t U Inspected By Inspector—D(l kkl �1­&S [��[9] <br /> . <br /> Ph cal dress - F Mo / <br /> Street <br /> Inspection Date U ,7 <br /> L tch � 9s��o I <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title QAM Q AM <br /> O PM m, 0 <br /> PM <br /> D Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole TE) 1 �.{ j� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active ®Passenger *iGenerator (0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude m Q Hauler ®Indoor <br /> I <br /> 0 QInactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container . <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader ®Dismantler Q Tire Derived Fuel <br /> Q 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 I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityENFORCEMENT STATUS <br /> V iMjHAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q 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(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip.Logs within 90 days (Required for NOV or DCT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years -- <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB 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 C-ompliance - No Violations <br /> O 1 O 1 Other: § <br /> Comment W� KJJ <br /> L�(L{ -e o <br /> V <br /> Art S ct!-e ccf.,_j a�in ✓p,6i e GCe SAk . �LYtZ � p M—O's <br /> Inspection Form Included: �.��/r �1 �f <br /> Comments.included:Qpslnes�s <br /> -— — q14 4r�7 i (Y� <br /> Rep's gnatu a Phone Number In Sign re- Phone Number <br /> ■ INSTRUCTIONS ON BACK Correct: Incorrect: 62081 <br /> M E' 1 2 3 ® S <br /> White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA LEA <br />