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== Waste Tire Suk . .:y & Inspection Repor' Inspection Report Number <br /> •• 1. <br /> State of California 1006 <br /> itiZ1 CIWMB181(New 04104) Survey Form - Page 1 14 - .� 0 0 0 72 0 <br /> ment Board <br /> California Integrated Waste Manage <br /> Part A- Survey_ - BLUE ORB_LACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` Inspection Type (Fill one) <br /> Site Suffix: L V ` ` Q Routine # Re-inspection Q Referral - Q Observation <br /> Local r, If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> \,A U'`v,�C,- .�'�/� <br /> Physical Address O "'�'L �{rar-A <br /> Inspection Date � l3. <br /> Time In ` Time Out <br /> Business Rep Title _ 0 AM 0 AM <br /> G� C> Z 5- 0 PM 3 5 ® PM <br /> -- - - - -- — - - - <br /> -- ----- - - - / —Operational Status Tire Type )', <br /> Business RStorage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply Fill all that apply) (Fill all that apply) <br /> ® Active I& Passenger ® Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck � <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> - <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body # 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 jHAULING AND MANIFEST REQUIREMENTS <br /> Q Q p Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <br /> Q Q 114 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days {Required for NOV orEX7) <br /> _ <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Ye eft 6 11NM �p �n ' <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 a "In'Conipliance' No iolations <br /> O 1 Q Other: § <br /> Comments <br /> w IL-5-- I/Vhad(, " • `- - - - -- —` - - - - <br /> o� Gc,rti 1�C . -tfby t. <br /> - - _. <br /> r <br /> Inspection Form Included- Q <br /> Comments Included: Q' - - <br /> �Business Rep's Signature <br /> - - Phone Number Inspector's Signature. Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct _ Incorrect � E:IX AIMIF � Y 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />