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Waste Tirequ & Inspection Reler pection Report NumberState ■ <br /> .03 � <br /> CIWMBfCalifornia Survey Form - Page 1 - -� - 10 -10 7 6 2 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board — --- -- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- t Inspection Type (Fill one) <br />} Site Suffix. ' 3 �� L_J - ��� Routine 0 Re-inspection O Referral 0 Observation <br /> Local `I If Referral,choose referral type(Fill one) <br /> Identifier: I j ( yL %4�j_ O CHP 0 CIWMB 0 Complaint O Educational Visit 0 Other <br /> Business or Facility game Inspected By Inspector <br /> Physical Address �✓ i _J i':` i . �/�i', _� <br /> Street Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0P � � DPM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply)', (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> O Active 0 Passenger O Generator 0 Outdoor <br /> � =o ® Closed 0 Altered <br /> Latitude <br /> GPS ', � Hauler 0Indoor '. <br /> (� o 0 Inactive Truck <br /> Longitude Q Planned 0 OTR End Use Container j <br /> III GGG <br /> Businessyp e (Fill all haapply) <br /> New Tie Dealer0 Auto Repair <br /> e air 0 Trucking Fleet � Government 0Retr„eader <br /> 0Dismantler 0 Tire Derived Fuel � <br /> O Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> O Service Station 0 Hauler O Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS _ Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O 0 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 Date <br /> M / FTI / M <br /> Q Q14CCR§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 EXT) <br /> Q 0 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 O In Compliance - No Violations <br /> O O (Other: § - <br /> Comments ((.._1 <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �/ <br />