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am W -RIM <br /> Waste Tire SAAy & Inspection RepospInspectionRe-port Number <br /> : <br /> ulMStateCalifornia Survey Form - Page 1 t O i31 <br /> CIWMBB 181 New 04/04) <br /> California Integrated Waste Management Board - -._-. <br /> 13 5 <br /> Part A- Survey LUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TSite SuffixPID_ V ( Inspection Type (Fill one) <br /> : (� � I I�I� <br /> ' 1 I 1 1 ��..� I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local n. f + If Referral,choose referral type(Fill one) <br /> Identifier: I r JLX_A U r1 (w ( 4 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ) Inspected By Inspector <br /> 1 <br /> Physical Address �— :�j <br /> J i <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title ®AM ®AM <br /> O PM ) f- O PM <br /> Operational Status ire Type Business Role Storage Type <br /> Tire Count(Whole/PTI.,ILL — (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / J ®Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude I� • Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> 11 apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ®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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments (((,iY111'1�L/1�"'(/ Ilf 0 4, L <br /> I k(6 Id. _; r �� ;� � I � «4 1 � 7,/,- <br /> -Til <br /> /-Tr '� , ^IC! ��� r ,t � f_tir2�, .�11�c�,^u ►nEr�� f o ( _ f_rQIM VC t,., (Ctr' <br /> Inspection Form Include <br /> Comments Included: Q - - <br /> Business Rep's Signature Phone Number Inspector's Signature <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X F-_Xj Will g 62081(P G L i(. 3 <br /> White Copy:CIWMB Yellow C:r,liv Opeiat(;r Pink Copy:LEA <br />