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-Liij Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB181(New04104) Survey Form - Page 1 1 1 0 0 8 0 9 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> ,Business Profile I Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> L Site Suffix: 4 Z - V 1 <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> c <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business R.Pll Title O AM O AM <br /> O PM O PM i <br /> t `Xl 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 /> ` V Q Active ® Passenger 0 Generator {#Outdoor <br /> � Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - 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 ® Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> i <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS.- <br /> V] <br /> TATUS.V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q EXtenilOff <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle mm <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date Eil <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB ' <br /> 'l7 <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or4Ss �r <br /> Q Q »�rn�mn'3 <br /> 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years I <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Reffrrbd f QW1111AB Onftiiril,e)El�ft <br /> 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 <br /> (�}14,_o m*P lid* No Ylt�ltlt ���, <br /> Q Q Other: § 1_ <br /> Comments _ U o� ��.9t�.5 J`r7VX11''VL — <br /> Inspection Form Included: <br /> Comments Included: Q;- <br /> I Business Rep's Signature Phone Number Inspect 's Signature Phone Number <br /> INSTRUCTIONS ON B cwt: Incorrsct: _ ( X NI P, L 1112 3 62081 <br /> _ - --Copy: -- <br /> White Copy:CIWMB Yellow Copy: Operator Pink Copy:LEA <br />