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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California Survey Form - Page 1 i 5 - 0 2 0 3 <br /> CIWMB 181(New 04104)California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: �— �^ I 4 Q Routine ®Re-inspection O Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C+� � r,.�� C-A O CHP 0 CIWMB 0 Complaint Q Educational Visit O Other <br /> Business or / <br /> Facility Name <br /> inspected By Inspector <br /> Physical ACtdrhss 3 47 <br /> C-.Jj Da."ue Dr <br /> Inspection Date © � � •3 L, � �J S <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> nn QPM QPM <br /> Operational Status Tire TypeBusiness Role Storage Type <br /> Tire Count (Whole/PTE) n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> L-. 1700 ® Active Q Passenger 0 Generator Is Outdoor <br /> O O Closed O Altered <br /> Latitude <br /> GPS Hauler ®Indoor <br /> O O Inactive 41Truck <br /> Longitude — O Planned O OTR End-Use O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair O Trucking Fleet O Government •Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> Q Service Station O Hauler O Agriculture 0 Shredder t)Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> U! A I HAULING ANO MANIFEST REQUIREMENTS <br /> -- PRC§42951-Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation O Extension <br /> O ra <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-RegistrationlDecal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / / m <br /> O O 1 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O j 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> ------...__......I..._.......- - <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O RefsrTed f CIWMB Enforcement <br /> O 4 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators iIp Campllancs - NO Violations <br /> O 00__ _ - - <br /> Other: <br /> Comments ��-G- ! � tq �p"e`a� ��1�-t`�I,T" W!"r►� � �Z��c7 W�'�r <br /> M <br /> Inspection Form Included: O <br /> Comments Included: Q VrW v QQEE�7 <br /> Business Rep's 5 ature Phone Number r s gn Phone Number <br /> X� 62081 <br /> INSTRUCTIONS ON BACK correaty m6i#r ft Y1,r 1 1 , PPL E; t L g ed <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br />