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03217040001 <br /> E 14 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Y Slate B 181 fornia Survey Form - Page 'I Il - '1086944 <br /> CIWMB 181(New nage). <br /> Callfomia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> - � I Inspection Type (Fill one) <br /> Site Suffix: I [ Is Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: (�n Ja u n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> LBusiness or Facility Name , 1 U <br /> Inspected By Inspector <br /> F_J�] _ <br /> Physical Address L3 �� L V _j <br /> Street <br /> Inspection Date <br /> CiLty��bState ZIP Corh L�O� o Time In Time Out <br /> C <br /> Business.Rep Title , F0 AM , i—� e AM <br /> O PM O PM <br /> _h1. C1o_.'�0.CCmi�10 O <br /> Operational Status Tire Type Business Role Storage Type <br /> �7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ` Q . <br /> f f b ®Active ®Passenger O Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 10 Car Dealer Q Collection Q Crumb Rubber <br /> )Service Station Q Hauler Q Agriculture Q Shredder Q Other I . I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VM HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 <br /> Q Q 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 EXE <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Referred!C-IWMB 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 Q Other: § <br /> Comments 0 t <br /> _6�n v-0 6oV5 V CIz4 -0.� <br /> T�:-- _jfflA4- <br /> Inspection Form Included: Q �a qf- Y r I <br /> Comments Included: Q 41ns�pe <br /> — <br /> Business Rep's ignature Phone Number isSignature Phone Number <br /> INSTRUCTIONS ON BACKo eet I:nco=rrecMt_ M1EjXjAjMjP1L1E1 1112 3 62081 <br /> "White Cop C Yellow Copy.Operator Pink Copy LEA <br />