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Waste Tire S�y & Inspection Repo Inspection Report Number <br /> I <br /> - <br /> CIWM of Survey Form - Page 1 1 7 - 10 7 3 4 0 <br /> CIWMB 181(New nage Y <br /> California Integrated Waste Management Board --- - - - ----.- -- ----.- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: t I r I 0 Routine 0 Re-inspection 0 Referral (3 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ( _i i (�; 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> !1 <br /> Physical Address 1 – <br /> J <br /> Street Inspection Date <br /> I - - ✓to",. I =1L <br /> city State ZIP Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> 0 PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> The Count <br /> (Whole/PT (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply)' <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 ® Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> --_-- <br /> 0 0 Inactive O Truck <br /> Longitude – 0 Planned 0 OTR0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> i 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility rENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 010 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments — <br /> t- i i 1 i l l i , - l' l U�;c a r 1/�n i vtl r✓�(r , i I I I I I <br /> ✓a lIo l 0ofi- ft-Cit) k1o (ICr of rk ATL ofliCf' <br /> rl !Ei'tiz,.c 'I r i I i-l( Cv,%/IC' i 1 - 0 L0 <br /> Inspection Form Included: 0 <br /> Comments Included: 0 ------- <br /> Business Rep's Signature Phone Number Inspegtor s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X I E XIA MIPILIE1 1113 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />