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Waste Tire ,,urvey 2K In 3pection Repui ., Inspection Report Number <br /> ka <br /> State of California - <br /> CIWMB181(New04104) Survey Form - Page 1 1 0 1 G 0' <br /> California 8 � <br /> California Integrated Waste Management Board rl <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: l <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> _ \ Inspected By Inspector <br /> �•r�S�^ �v�S�V�'�O 1n 1 <br /> Physical Address 6. <br /> Inspection Date <br /> 06 / L <br /> Time In Time Out <br /> Business Rep Title / O AM O AM <br /> \\ (� ( 't' ' O 0 ® PM Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> i Active ® Passenger ip Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <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 ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> -- - - - - ------- ----- - ----- --- -- - - <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Trans----rt of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Ha_=-s. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with t.'anifesting Requirements Date <br /> m <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number f­_m CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and T-e Trip Logs within 90 days (Required for NOV or EXT) <br /> 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/CIWMB Enforcement <br /> Q Q 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 C Z_`` 1 � V 3D �_ GtH W7.1$,-� � DNA S �" r_ <br /> .1 l <br /> ((�� c6o 11 S�� " 4- 11r <br /> ���,l,�-�.�g� ���o��.1� t� �e �,^.. CX <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Reps Signature Phone Number tor,s nature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X �,, E X1a h4 ?. 62081 <br /> White Copy:CIWMB Y- .r, Copy:Operator Pink Copy LEA <br />