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® Waste Tire Sui ..:y & Inspection Report ispection Report Number ■ <br /> State of California <br /> CIWMB181(New04104) Survey Form - Page 1 i - 10 6 6 1 3 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: J ✓ ll <br /> 4 � 2 � ec— J � 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �p�� ���`\ � l� �,;<MQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U Inspected By Inspector <br /> Physical Address ` - ` \��(ciC w is Ccx-\r- <br /> / 3 Inspection Date CA 2 J 5 <br /> \A ����"`� � 1 _ Time In Time Out <br /> Business Rep Title O AM O AM <br /> J Z ® PM J Z- 7 ® PM <br /> 1 Operational Status Tire Type Business Role Storage Type <br /> � <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)6 � <br /> t t ® Active ® Passenger ® Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer ® Auto Repair Q Trucking Flee: Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 1# 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 Q Notice Of Violation Q Extension <br /> �Q Q PRC§42951 -Waste Tire Hauler Registration -ransport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste- Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complyi-; ;•!tn Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID N--cer from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Four; and Tire Trip Logs within 90 days (Required for NOV or Exr) <br /> ----------------------------- <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms a-d Tire Trip Logs for 3 years <br /> ---- - -- — <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements*cr Waste Tire End-Use Facilities <br /> Q ® 14 CCR§18462- Manifest System Requirements'or Tire Dealers or Waste Tire Generators ® in Compliance - No Violations <br /> O O Other § - <br /> Comments `( lV�,7��J v\ �.���� �' S �pl.� t ' Y"�- -t'O��dad✓` Lti chi L�'dl/� , <br /> V\.-5 P� t\, <br /> Inspection Form Included: Q <br /> • ' � Vre <br /> Comments Included. tk LQ Business ep's SignatuPhone Number Inspector's Signature Phone Number <br /> I --- 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X XNt <br /> White Copy CIMS Yellow Copy Operator Pink Copy LEA 61 =4 <br />