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`��� Waste Tire Sur, y & Inspection Report inspection Report Number <br /> j CIWMState B <br /> f 81(New Survey Form - Page 1 - o] <br /> fnia CIWMB 181(New nage <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile nspection Details <br /> TPID- ., � ( - Inspection Type (Fill one) <br /> Site Suffix: ' ' �:- V <br /> ® Routine 0 Re-inspection 0 Referral Q Observation <br /> Local 1 - If Referral,choose referral type(Fill one) <br /> Identifier: 7 �;ft 0 f. f Vt r O CHP Q CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address I I I – <br /> B - <br /> � <br /> Street P <br /> i Ins ection Date <br /> CitL v State ZIP Code Time In Time Out <br /> Business Rep Title I� O AM O AM <br /> 0 PM m m 0 PM <br /> Operational Status Tire Type Business Role torage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) Fill all that app <br /> Tire Count (Whole/PT �) <br /> O Active 0 Passenger � Generator Outdoor <br /> O Closed Altered <br /> Latitude <br /> GPS Q Hauler O Indo <br /> _- O ® Inactive 0 Truck <br /> Longitude – O Planned O OTF End-Use ontainer> <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> 0 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 I A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / m / M <br /> Q 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB 17 <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 Q 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 <br /> In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> T L01- <br /> ✓1 f'�LrlC — i' f ,� ✓1(- `�/I�r!`t .11i (/t'IfVl <br /> ( 1' f <br /> IT— <br /> Inspection Form Included: <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signatur Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X i ,,A M P L 6201 f 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />