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Waste Tire Sui - ,Ay & Inspection Report Inspection Report Number ■ <br /> �» State of California <br /> CIWMB 181 04/04) <br /> I 1 - 114 0 8 8 8 <br /> California Integrated Was eeManagement Board Survey Form - Page 1 <br /> Part A- Survey _ --_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Z - © / Inspection Type (Fill one) <br /> Site Suffix. 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �yf In Q CHP 0 CIWMB Q Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address / - / U <br /> /Ue(/6' �i✓t <br /> Inspection Date .Z. / <br /> Time In Time Out <br /> Business Rep Title L, O AMQ AM <br /> �/ T ® PM O �S �7F d ® PM <br /> - / - -- 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 /> •Active 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - ® OTR Q End-Use Q Container <br /> 0 Planned <br /> Business Type (Fill all that apply) /V/,4 <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture Q Shredder ® Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (a In Compliance - No Violations <br /> Q Q 1 Other: § <br /> Comments <br /> IJ ------ <br /> Inspection Form Included: 0 X "� <br /> Comments Included: ® —---- -- <br /> Business Reps Signature Phone Number Inspector s Signature Phone Number <br /> �l 62081 <br /> INSTRUCTIONS ON BACK Correct:-Incorrect: X ,`H X A 1112131 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop : ® ■ <br />