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Waste Tire Sud .y In pe tion Report ,dspection Report Number <br /> 171 State of California <br /> CIWMB 181(New 04104) S u rVe F <br /> rm - Page1 1 .1 - 1 0055125 <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> - - ----- <br /> -- - <br /> Business -- <br /> Profile -- - - <br /> -- Inspection Details <br /> TPID- - - -- - - - <br /> Site Suffix: Inspection Type (Fill one) <br /> — - __- _- - ® Routine Q Re-inspection Q Referral Q Observation <br /> I Local <br /> Identifier: If Referral,choose referral type(Fill one) <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - ------ - _ <br /> Inspected By Inspector <br /> �w'eXccetw <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title / 2 0 AM 0 AM <br /> ® PM v ( f PM <br /> U - - 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 /> vActive' i I Q Passenger Generator Q Outdoor <br /> GPS Latitude -- Ired' ( Q Altered <br /> Q Hauler Q Indoor <br /> O I tive Q Truck <br /> Longitude - Q Planned Q OTR Q 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 Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber ,I <br /> Q Service Station Q Hauler Q Agriculture Q Shredder IV Other AV" ��JJ//f�f- 0At-7Q -0e— <br /> art B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility i ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation <br /> Q I Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Extension <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 ® 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or.EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers n y g <br /> f c' <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 Generatorsza. <br /> Q O Other: § e, <br /> — -- <br /> Comments <br /> /3 <br /> - <br /> /u e5- Co7_ s _ /rrs -OkiAll <br /> Inspection Form Included: Q <br /> Comments Included: Q _-5 �CJ fi8 <br /> - Business ep s Signature Phone Number Insp ature Phone Number- <br /> 62081 <br /> umber_ f <br /> INSTRUCTIONS ON BACK Correct: Incorrect t � x }t' P L 1 2 3 62os1 <br /> - -- X q <br /> White Copy:CIWMB Yellow Copy:Crerator Pink Copy:LEA <br />