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:., <br /> Waste Tire Sy &' Inspection Repollnspection Report Number ■ <br /> '-- State of California .+t <br /> r� CIWMB181(New 04104) Survey Form - Page 1 - ,� <br /> California Integrated Waste Management Board -- - - - - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix. f� (� - '� <br /> � @ Routine Q Re-inspection Q Referral Q Observation <br /> Local - If Referral,choose referral type(Fill one) <br /> Identifier: - r _ ; Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical <br /> Street `) <br /> Inspection Date <br /> City State ZIP Code Time In Time Out OAM <br /> Business Rep Title d C 0 PM �� Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that appfo:: (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger Q Generator Q Outdoor <br /> GPS ' I ,�W o Q Closed Q Altered <br /> Latitude <br /> —�—( Q Hauler Q Indoor <br /> nQ Inactive Q Truck <br /> j L <br /> Longitude - 10 <br /> Q Planned Q OTR Q End-Use Q Container <br /> Busiviess Tyir. (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 /> - <br /> V A-1-HAULING AND MANIFEST REQUIREMENTS <br /> Q Q § - -------- ---- Q Notice Of Violation Q Extension <br /> 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 <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q 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 Q Referred I CIWMB Enforcement <br /> QQ 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 <br /> Inspection Form Included QI rrX,t W „µ,(N _ t .,d' ,, rig(a tyai tiff " i <br /> ' a <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number/ Inspectors SignaturePhone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X( V m <br /> h� <br /> f - �� 62081 <br /> • �` <br /> }}t ■ <br /> S. <br /> x White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />