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FORM NO.M-105547-CIWMB M12 1607 — 987654321 , <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Stateof BCalifornia Survey Form - Page 1 19 - 1 0 7 3 4 8 1 <br /> CIWMB 161(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- n tb Inspection Type (Fill one) <br /> Site Suffix: 2 T j 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1_ Inspected By Inspector <br /> VV <br /> Physical Address <br /> 3 o J 0 <br /> _ Inspection Date I Z i Z O <br /> Ir c7 cl� 15.30`/ <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ®PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type: <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ® Passenger ® Generator O Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler O Indoor <br /> O O Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer ®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 O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> �. - <br /> V A HAULING AND MANIFEST REQUIREMENTS _ Q Notice Of Violation Q Extension <br /> I <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. I'Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m m <br /> 14 CCR 18459.1 -Tire Program ID Number from CIWMB m �^ <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 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 /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q ® In Compliance No�,Viotations <br /> Q 1 Q Other: § - <br /> Comments <br /> ��'lti �11Y.�G.�'1�/•�_—��-�Ifq� f�/`t6.l�C . ��-��� f!7 i'nt}c�t��/ Cdc�. —� <br /> A.1 <br /> Inspection Form Included: Q <br /> OL 23 <br /> Comments Included: Q <br /> Business R 's Signature L43hone Number Inspector's Signature Phone Number <br /> r—,-- ---, s9f1R1 <br />