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=lE , Waste Tire SlIvey & Inspection Repo# Inspection Report Number <br /> State of californla <br /> CIWMB181(Now04104) Survey Form - Page 1 1 5 - 10 2 5801 <br /> CaMornla Jntegrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> (Business Profile I Inspection Details <br /> TPID_ a _ Inspection Type (Fill one) <br /> Site Suffix: C� S J® Routine Q Re-inspection Q Referral Q Observation <br /> I� Local If Referral,choose referral type(Fill one) <br /> Identifier; Q CHP Q CIWM8 Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> IInspected By inspector <br /> Physical Address <br /> LA <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title j O AM O AM <br /> O PM O 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 /> r r C I ® Active ® Passenger Generator Outdoor <br /> O I Q Closed 1 0 Altered <br /> Latitude <br /> GPS Q Hauler Q Indoor <br /> O + Q Inactive Q Truck <br /> Longitude - ! Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that 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 ENFORGEMENT_STATU3 j <br /> : A HAULING ANO-MANIFE3T R1CUIREM NT8 j <br /> O O 1 Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O + O PRC§42953-Contracts vnth Registered Waste Tire Haulers. 1 Compliance Deadline <br /> Q � Q PRC§42956-Registration/Decal in Vehicle <br /> Q I O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date ( I ( I f <br /> Q Q t 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 114 CCR§ 16459.2.4 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requiredfor NOV orEX7) <br /> Q Q 114 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years I — -•._•____......___ ) <br /> Q I O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q gpferredl.GlVll?M8 Enforcement <br /> 01 O 14 CCR§ 18461 •Manifest System Requirements for Waste Tire End-Use Facilities <br /> f <br /> 01 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators + In 6dnp1latitn5 No u11014pons <br /> Q_LQ I Other: <br /> Comments [� _ Q �- <br /> NC� \ y'�V+ _" L�i ,k`'L QI `�'� V4 oto <br /> SS <br /> Inspection Form Included: Q <br /> Comments Included: Q - U� <br /> Business Rep's Signature hone Number,► Ins ector's Signatu Phone Number <br /> INSTRUCTIONS ON BACK (066.6 k;� )#1r F11'#_ < VJ j Er_ �Rlll4)�P I G� � 1 1 213 62081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />