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Waste Tire Sur*y & inspection ReportOnspection Report Number <br /> a <br /> State of California %g F"} �s I`t <br /> 1CIWMB 181(New 04104) Survey Form - Page 1 `F '_ <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> i <br /> TPID- 11 Inspection Type (Fill one) <br /> Site Suffix: t IC.I `� t 0 Routine Re-inspection 0 Referral 0 Observation <br /> Local ,[7- - i If Referral,choose referral type(Fill one) <br /> Identifier: LA,k 01. ;' � . 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> r <br /> Street Inspection Date <br /> State ZIP Cotte I Time In Time Out _ <br /> Business Rep TitlO AM FT <br /> eOAM <br /> O PM O PM <br /> J' <br /> Operational Status Tire Tallype <br /> , Business Role Storage Type <br /> (Fl one only) (Fill app y)'- (Fill all that apply) (Fill all that app <br /> ly)The Count (Whole/PTE) ; <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> LatitudeO 0 Closed 0 Altered <br /> GPS �.� ' 0 Hauler 0 Indoor <br /> Inactive 0 Truck <br /> Longitude OTR 0 End-Use 0 Container <br /> Planned <br /> Business Type (Fill all that apply) <br /> 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 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 M / M / Ffl <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 0 in Compliance - No Violations <br /> 0 0 Other: <br /> Comments <br /> i <br /> i <br /> Inspection Form Included` 0 <br /> Comments Included: 0 - <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X Y y ',; :,M P L E i 1 I a'_' 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />