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Waste Tire Sur y & Inspection Report inspection Report Number <br /> " i;_ State of California <br /> "'"` Survey Form - Page 1 # - 1006356 <br /> " CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile inspection Details — <br /> Site - , - Q Inspection Type (Fill one) <br /> Site Suffix: ''' 'I �11 I � � r S Q Routine Q Re-inspection Q Referral (D Observation <br /> Local .— If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street <br /> �- {. C ; !� �_ _'1r-- Inspection Date <br /> State ZIP Code Time In Time Out <br /> Business Rep Title Q AM O AM <br /> ' O PM f O PM <br /> Operational Status Tire TypeBusiness Role Storage Type <br /> Tire Count(WholelPT (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger Q^Generator Q Outdoor <br /> O Q Closed Q Altered <br /> II GPS Latitude � ral;� Q Q <br /> Hauler Indoor <br /> O Q Inactive Q Truck <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill al)that apply) i <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 <br /> 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 / F7 <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 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/CIWMB Enforcement <br /> 014 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 700 Q14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> QI Other: §, <br /> Comments <br /> r <br /> pection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone NumberInspector's Si9pature Phone Number <br /> " <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ,�- \/ E X A rJ+I jL�E i 62081 <br /> 3 j <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />