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■ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> 8ar1 State of California _ <br /> CIWMB 181(New 04104) Survey Form - Page 1 I1 1141011 <br /> California Integrated Waste Management Board <br /> Part A- SurveyBLUE ORBLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- //��� ((�� q Inspection Type (Fill one) <br /> Site Suffix: ` O o V 1 a 1 ® Routine O Re-inspection O Referral O Observation <br /> Local Sa O � If Referral,choose referral type(Fill one) <br /> Identifier: (�,�j , O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Add4s Of &,n Esc�L <br /> S C A 15-M Inspection Date 9 <br /> Time In I Time Out <br /> Business Rep Title 0 AM0 AM <br /> PM I D A PM <br /> tk-ik V�C 5't)'IL4S^ CC <br /> - Vis.+_(.r_mt(�/y� - - <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 /> • Active ® Passenger ® Generator • Outdoor <br /> Q Closed i O Altered <br /> GPS Latitude O Hauler O Indoor <br /> O Q Inactive O Truck I <br /> Longitude — O Planned O OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ' <br /> A HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation O 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 Date M / m / m <br /> O O 114 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O I'I O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> - - <br /> OO 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred I 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 Compliance - No Violations <br /> O O Other: § -- - <br /> ( ' a <br /> Comments <br /> Inspection Form Included- O 31' <br /> Comments Included: <br /> Business Rep's Signature Phone Number �In s tor's Signa re Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct 9 Incorrect VI A I I I Z 3 <br /> ■ - - - ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cy:L <br />