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is <br /> =' Waste Tire Surty & Inspection Report Inspection Report Number <br /> State of California <br /> "VCIWMB181(New 04104) Survey Form - Page 1 1 1 - 10 1 3 6 6 41 <br /> 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 �j J Yj rj I O Routine O Re-inspection O Referral O Observation <br /> Local F: If Referral,choose referral type(Fill one) <br /> Identifier: :, ;_ f r e-i O CHP Q CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date <br /> i.: <br /> Ciitty-- State Z/P Coc Time In Time Out <br /> Business Rep Title O AM _ Q AM <br /> O PM S Q PIV1 <br /> Operational Status rh e Type Business Roleorage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) all that appl, <br /> Tire Count (Whole/PTE �� �^ U <br /> ® Active 0 Passenger O Generator utdoor <br /> Latitude O Q Closed 0 Altered <br /> C7P$ ® Hauler Q Indoo <br /> I D Q Inactive 0 Truck <br /> t Longitude — I 0 Planned O OTR O End-Use Q Container <br /> that apply <br /> 16 <br /> O New Tire Dealer 0 Auto Repair O Trucking Fleet O Government Q Retreader O Dismantler 0 Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> O Service Station ® Hauler O Agriculture Q Shredder O Other I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - 0 Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q O 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 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O 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 Q In Compliance - No Violations <br /> O O Other: § <br /> Comments ` <br /> Inspection Form Included: 0 <br /> Comments Included: 0 -- - - - ' <br /> Business Rep's Signature Phone Number Inspector's Signature <br /> G, <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X "v i E!'X A 04 P I L111273 62081 EI <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />