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`111I!ka <br /> i: ire Sur.� & Inspection Report Vection Report Number <br /> Waste T �/ p p <br /> State of Californiai1 i1J 5 U 9 CIWMB181(New 04104) Survey Form - Page 1 �1 V V <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Inspection Details <br /> Business Profile <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: L) �. C1 ` Q Routine ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SC\h �oet�� v� �c��h Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address t '~� <br /> Inspection Date ` \ 1 61 <br /> Time In Time Out <br /> Business Rep Title ® AM ^- ® AM <br /> d o : 30 Q PM 1 ' "L 0 O PM <br /> C> <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) , <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> PS Latitude 0 Q Closed Q Altered Q Hauler Q Indoor <br /> G <br /> O Q Inactive Q Truck <br /> Q End-Use Q Container <br /> Longitude - Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS ® Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> ® Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date p <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> ® Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 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 /> Q Q Other. § _ -- <br /> _ I—l,,v d <br /> Comments <br /> � k,j�,Ac,,� 'i <br /> t <br /> (t . _lV\� L'.0—`` lU� ljiil/y�ll�-�Z� 15 r�ob�-L ► V� �a I o L <br /> 1►�\ b�k � tiMv>v` LTL ►. <br /> LU �t--t-S <br /> Inspection Form Included: Q (r� 1��_+:!r <br /> _�� S �- <br /> Comments Included: Q / I J L In ector's Signature Phone Number__, <br /> Bus' ess Rep's Signa ure Phone Number 9 <br /> __.'._/ 62081 <br /> INSTRUCTIONS ON B CK Correct: Incorrect:X � ,+ �/ I X A Nf P L �; I <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />