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i <br /> Waste Tire SL&y & Inspection Repor <br /> Slate of California ` WrtspectionReport Number <br /> �_.. <br /> Survey Form - Page 1 $ - <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> Site - Inspection Type (Fill one) <br /> Site Suffix: �✓ (j (� - Q Routine Re-inspection Q Referral Q Observation <br /> Local y If Referral,choose referral type(Fill one) <br /> Identifier: r ( tt n L u ytt Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date <br /> a t-� --- <br /> city State ZIP Code Time In Ou <br /> Business Rep Title O AM <br /> 10A <br /> OPM m ' m 0P <br /> Operational Status Tire Type Business Role forage Type <br /> Tire Count (Whole/PTE' j- l (Fill one only) (Fill all that app (Fill all that apply) Fill all that apply) <br /> G ® Active Q Passenger Q Generator Outdoor <br /> Latitude . <br /> O Q Closed Altered <br /> GPS i Q Hauler Indoor <br /> 0 Q Inactive Truck <br /> Longitude — Q Planned OTR, Q End-Use Container <br /> Bus <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 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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § <br /> Commentsf <br /> ��� < , ! 1 f b; fry (tft _ ( flylrt), <br /> l`lo! (�c>( X111 o S I ���� �� 1�c� y� ��� ,�, (��rQC �y� � No <br /> r <br /> Inspection Form 'Included: <br /> Comments Included: Q =- <br /> Business Rep's Signature Phone Number Inspector's S nature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X _�`X[RVd F I L I E 1 11 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />