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00 <br /> Waste Tire Survey & Inspection Report Inspection Report Number M <br /> State of California /04) Survey Form - Page 111 - <br /> OMB 181(New 04 1143501 <br /> C <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- S <br /> Inspection Type (Fill one) <br /> Site Suffix: <br /> Routine 0 Re-inspection 0 Referral 0 Observation <br /> % <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 10"W r\ CL7 A 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Add,7r ;-1 0 ��,n <br /> C(I <br /> CA I533 Inspection Date O I o <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> ! PM PM <br /> Status Tire TypeBusiness Role Storage Type <br /> (Fill one only) (Fill all that <br /> apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 1 0 Active __9 Passe--n9 e-r 41IGenerator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 inactive Is Truck 0 Hauler 0 indoor <br /> 0 <br /> Longitude 0 Planned OTR 1 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 crumb Rubber <br /> 0 Service Station 0 Hauler Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility 1ENFORCEMENT-STATUS-.------------. <br /> V I A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 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 M / m <br /> / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities -1-1--.111.- -1------- <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators in compliance No Violations <br /> 0 0 Other: § <br /> Comments <br /> 11� On <br /> o-4 <br /> I " <br /> Inspection Form Included- 0 <br /> joa <br /> %7 -1 <br /> Comments Included: <br /> Business Re Signature Phone Number �InpVer,Siu7 <br /> gnat hone Number <br /> - <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: P X <br /> XIA M L 1 112 3 <br /> MWhite Copy:CIWMB Yellow Copy:Operator Pink Cop M <br />