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Waste Tire Sur . .-Ay & Inspection Report dnspection Report Number <br /> State of <br /> CIWMB 181'(New 04104) I 1 - 114 0 9 5 0 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> PartA-_Survey_ -- - _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Profile --- <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 0 3 3 �/ © ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: 1::_�,LA� `roC ,t,J 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ��J ( — <br /> Inspected By Inspector <br /> Physical AddressCA <br /> C} Inspection Date <br /> ` �33 Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 O2 O ® PM U o2 O ® PM <br /> Pao-, <br /> --- -- — ----- -- r 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 /> IS Active ® Passenger ®Generator ® Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 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 /> 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 ENFORCEMENT STATUS <br /> V , A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 0 Notice Of Violation 0 Extension <br /> 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 /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 i 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <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 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments " <br /> ---�llcfZtr_v�- yv'r're!' IZU�C-� •' -- -- ---- _ - -- -_ - --- <br /> Inspection Form Included: 01 <br /> Comments Included: ® - - - - -- - - - — - - ---r <br /> Business Rep's Signature Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect �i !w X A (� 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy: ■ <br />