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Waste Tire SMey & Inspection Repoft Inspection Report Number ■ <br /> State of California - <br /> CIWMB181(New 04104) Survey Form - Page 1 _ I <br /> California Integrated Waste Management Board -' _ z <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br />} �TPID- Inspection Type (Fill one) <br /> Site Suffix: (� - 11 <br /> �O Q Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: Ca CIO C t l 1F 1 CO ��) <br /> I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> Physical Address L�3 - <br /> on <br /> Street <br /> Inspection Datecihl t f <br /> _tate _1P Co_ � Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> O PM __„- ----� 0 PM <br /> OFill one only)I Status FI II T that apply) Business Role Storage Type <br /> p Type <br /> Tire Count (Whole/PTE) ( y) ( pp y) (Fill all that apply) (Fill all that apply)' <br /> ' ® Active Q Passenger (A Generator Q Outdoor <br /> _ 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> - --� • � � �� Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> - <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 Registrn 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 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 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 § Y q - <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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> g o <br /> LA )\ , --Tor-e __Qa <br /> Inspection Form Included: - - <br /> Comments Included: Q <br /> _. . <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> / 62081 <br /> INSTRUCTIONS ON BACK Correct:® incorrect: X �/ I ;`'” AA[ L <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />