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Waste Tire Sufty & Inspection Report&Inspection Report Number <br /> --�I State of California <br /> CIWMB181(New04104) Survey Form - Page 1 1 3 - 10 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey' BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- r. Inspection Type (Fill one) <br /> Site Suffix: (f ` t <br /> / � , - J Q Routine Q Re-inspection Q Referral Q Observation <br /> Q CHP QCIWMB QComplaint <br /> QEducational Visit QOtherLocal If Referral,choose referral type(Fill one) <br /> Identifier: <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address - ! �! ( h y, t rr , <br /> Street ,' <br /> Inspection Date <br /> Citv State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> j / ' O PM O PM <br /> Operational Status Tire Type Business Role Forage Type <br /> Tire Count (Whole/P r (Fill one only) (Fill all that apply) (Fill all that apply) 7Fill all that apply) <br /> L.' <br /> a Active Q Passenger Q Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude W . � Q Hauler Q Indoor <br /> � Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that ap <br /> Q New Tire Dealer Q 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 ® 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 Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 114 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 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 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 /> J <br /> Comments j)�(� � �' - -� - `` 1� r l��.�t i- C ' ( Ij? L L ol 4I _ <br /> �r,l ✓U k �+ccc <br /> U - <br /> Inspection Form Included: <br /> Comments Included: Q <br /> --Business Rep's Signature Phone Number Inspector's Signature Phone Numb, <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X ]A 041P I L I E 1 11 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />