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Waste Tire Surly & Inspection Report •Inspection Report Number ■ <br /> State of California J <br /> r, <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey— ---- - - — — - ---_- BLUE OR BLACK INK PEN <br /> (Business Profile L . Inspection Details _ <br /> TPID- - � ! Inspection Type (Fill one) { <br /> Site Suffix: /�I Routine Re-inspection Q p Q Referral Q Observation <br /> Local / -^ + ' j If Referral,choose referral type(Fill one) <br /> Identifier: <br /> v Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> p y Inspector <br /> Physical Address <br /> Street - -----I. Inspection Date F EoECflD/ �_____ _ -~Slate ZIP Code Time In Time Out <br /> Business Rep Title MF Q AM ' <br /> ' O AM <br /> O PM O PM <br /> - Operational StTire Typeusiness Role <br /> atus Storage Type <br /> The Count(Whale/PTE) a f (Fill one only) (Fill 611 that apply) (Fill all that apply) '(Fill all that apply); <br /> Q, Q Active Q'Passenger Q Generator 1 Q Outdoor <br /> Hauler Indoor <br /> GPS Latitude C Q Closed Q Altered Q Q <br /> -' - Q Inactive Q?Truck <br /> C <br /> Longitude - � w Q Planned Q OTR Q End-Use �Q Container <br /> Business Type (Fill all that apply)' il <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 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 Ill m / El 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 <br /> Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> - - --- -- <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I 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 /> Q Q Other: § Q In Compliance - No Violations <br /> Comments <br /> =T <br /> fnspection Form Included: Q� <br /> r <br /> Comments Included: QI <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X ,�W {L ,+,, r `L C 1 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />