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® Waste Tire SuuVey & Inspection Report*-Inspection Report Number <br /> ~� State of California a,® <br /> CIWMB 181(New <br /> Manage) Survey Form - Page 1 I1 1141178 <br /> California Integrated Waste Management Board Y � .___..._.. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> BuslneSs Profile Inspection Detal: <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: , 1 <br /> 1 0i QRoutine QRe-inspection QReferral QObservation <br /> Local — If Referral,choose referral type(Fill one) <br /> Identifier: r i <br /> U��� �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> f � _I <br /> Physical Address 1c, <br /> t....... ........... o�j c�j ...................... ............... ___T_, FT <br /> - Ao— -__"(d <br /> st;¢ r <br /> r <br /> Inspection Date Q <br /> < w tc-t? P;91, Time In Time Out <br /> Business Rep Title <br /> O P M <br /> i 0 AM <br /> o PM <br /> L3_�_. ._.. 3 ?�__) (0 PM <br /> Status �1 ire Type Business Role Storage Type <br /> �� Operational <br /> I(Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply)' <br /> Tire Count (Whole/PTE) (; <br /> f Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O <br /> Q Inactive O "i'ruck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST-REQUIREMENTS <br /> - - - -- - --- --- ------------------ Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle m <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB m m FF, <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <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 Generators Q;In Compliance - No Violations <br /> Q Q Other: § <br /> Comments I <br /> T <br /> � V��t `- �� join -+ � o;' ; i c_. a c� _ .t i ,•, r i r�l I <br /> 1 !r� j <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Nurr-?ber Insp,_c-or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X /- , 62081 <br /> L F <br /> ■ While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />