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t�. <br /> Waste Tire Su', ,y & Inspection Report nspection Report Number ■ <br /> bill - State of California — <br /> CIWMB 181(New 04104) Survey Form - Page 1 I1 1140669 <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: / Q Routine Q Re-inspection Q Referral ® Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Cc�w Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> I Business or Facility Name J1 Inspected By Inspector <br /> �.1 <br /> Physical Address <br /> y <br /> Inspection Date <br /> rummy <br /> CA C1537t. <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> r C ® PM oZ ® PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> 1 1 � <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> - - 0 ® Q <br /> Closed Altered <br /> Latitude <br /> GPS Q Hauler Q Indoor <br /> o ; Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> 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 <br /> -- --- --- -- ] Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 m / m / m <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 EXT) <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 Q Referred 1 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 <br /> In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Y <br /> IVL" f,'�z c c r c Lh'u l�J Q I Sc�vcr� ct �✓ [� /�'f c�• - <br /> Inspection Form Included: QI --7 <br /> --- ✓� <br /> Comments Included: Q -- -- - - -- - <br /> j -- Business Rep's Signature Phone Number spector's Signature Phone Number <br /> t 62081 <br /> INSTRUCTIONS ON BACK � � F' E; fku L 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C ky <br />