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«" Waste Tire Survey $ Inspection Report Inspection Report Number ■ <br /> . <br /> r� State of California <br /> CIWMB 181 e <br /> Callfomla IntegratedWaste Management Board Survey Form - Page 1 1 2 - 1079299 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / �/J� �/ Inspection Type (Fill one) <br /> Site Suffix: / I � I �13 ��q�Y1 _ D ( a Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S/4N J 6 O CHP Q CIWMB Q Complaint. Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> r:� sly yo 1 - IDDI <br /> Physical dress 3 <br /> Street <br /> Inspection Date <br /> ock- 9 57021 <br /> City State ZIP Coca Time In Time Out <br /> Business Rep Title ' <br /> MOPM m' O PM <br /> - � NC �---'--- � - — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> S I I � . <br /> f f 0 Active 0 Passenger 0 Generator Q Outdoor <br /> l j I j Q Closed Q Altered <br /> IO <br /> 0GPS Latitude I I Hauler Q Indoor <br /> --' - -- -'- O Q Inactive 0 Truck <br /> End-Use Q Container <br /> Longitude <br /> O 0g -I. O Planned OTR - <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair O Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> IS Used Tire Dealer 0 Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> I <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A RULING AWMA78 IFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Lags for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 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 •In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> Zo <br /> Inspection Form Included:Q <br /> Comments Included:Q --- - <br /> Bu iness Rep a Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON B CK orre-t:4WA Incorrect: E X A M P L E' 1112131 62061 <br /> ■ White Ctr <br /> Yellow Copy:Operator Pink Copy:LEA <br />