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-$ . Waste Tire Sur .y & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB181 <br /> Waste <br /> Survey Form - Page 1 1 2 - 1 0 1 0 5 8 <br /> California Integrated Waste Management Board I <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- .L /' I , - h J Inspection Type (Fill one) <br /> Site Suffix: `Q outine 0 Re-inspection 0 Referral IS Observation j <br /> Local , / If Referral,choose referral type(Fill one) `- <br /> Identifier: -1 C0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> y <br /> 2 tl,z 3 - <br /> Street <br /> r Inspection Date <br /> I � ncle ;1 , <br /> City _ <br /> State ZIP Code Time In Time Out <br /> Business Rep Title m ' FFI 0 AM 0 AM <br /> O PM FII ' m O PM <br /> Operational Status Tire Type Business Role S Drage Typ <br /> The Count(Whole/PT (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that ap <br /> 0 Active 0 Passenger 0 Generator 0 Outdo <br /> O 0 Closed 0 Altered <br /> GPS LatitudeTTI 0 Hauler 0 Indoor <br /> t7 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use G <br /> usiness Type (Fill all that appl` <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 /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other A <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 FP / m / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 /> ( Ct / <br /> I/C L aw yo rA:. <br /> Gll<�.f + /'JVD((( ►}✓ ! (/i'`. ( �'lt ( � f✓Vc C -�� feS l�� 1 �t� �ll i:r; � — ./rt A <br /> Inspection Form -1 tide <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's SignaturN Phone Number <br /> r+ 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X �., E;x A 0PI P L E 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />