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4- <br /> a <br /> Inspection Report Number <br /> Waste Tire S & Inspection Repo _p p <br /> seems➢ State of California Y I h a ■ <br /> CIWMB181 <br /> Waste <br /> eManag) Survey Form - Page 1 1 3 - X 0 1 3 4 6 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I f Inspection Type (Fill one) <br /> % <br /> Site Suffix: n r% ?I r. r <br /> Q Routine O Re-inspection Q Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: '� i_ ,r O CHP Q CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> p y Inspector <br /> Physical Address —� <br /> .\ . r.?1 f <br /> Street <br /> Inspection Date <br /> Time In Time Out <br /> C'ifv State ZIP Code I <br /> Rep" Title / / 0O AM <br /> O PM 1 L/ _ PM <br /> Business Re Q AM <br /> I'MiOperational Status Tire Type Business Role Storage Type <br /> pho <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count �r hoBe/PTE; �^ <br /> Q Active Q Passenger O Generator 0 Outdoor <br /> O Closed 0Altered <br /> GPS Latitude ® Hauler 0 Indoor <br /> O Inactive p'l"nick <br /> �^ O <br /> Longitude – O Planned O OTR O End-Use 0 Container <br /> „gMd�W _ - - <br /> Business Type (Fill all that apply) <br /> O New fire Dealer Q Auto Repair O Truckin leet Q Government Q 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 ��® Hauler O Agriculture O Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, auler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> --- – 0 Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport o ires <br /> .0 O PRC§42953-Contracts wit egistered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Dec in Vehicle <br /> O O 14 CCR§18459 -Responsible Ent 'es Complying with Manifesting Req 'rements Date m / m / m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Pro am ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manife Forms and Tire Trip Logs within 9 ays (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest For s and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requiremen for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Ste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire alers or Waste Tire Generators O In Compliance - No Violations <br /> O 1 O Other: § <br /> Comments �t \ <br /> f _ <br /> r> <br /> Inspection Form Included: <br /> Comments Included: 0 -. <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 6208'1,�ti< '- Nt L <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />