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■ Waste Tire S69y & Inspection Reporo Inspection Report Number ■ <br /> State of California I 1 — 1108417 110 8 417 <br /> r >� Survey Form - Page 1 <br /> CIWMB 181(New 04104) <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: 1 J 1 .� fI IQ Routine Q Re-inspection Q Referral Q Observation <br /> Ll <br /> Local _`_N --I I ,� f If Referral,choose referral type(Fill one) <br /> Identifier: jr!t r.\ ( �;Z!yi,. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> Physical Address - ✓ I F/ <br /> to <br /> Street - Inspection DateFT-1 <br /> --- -- --- <br /> State 71F'Code Time"In Time Out <br /> Business Rep Title ( O AMPM L O AM <br /> p� ({{II (/_ //fit �f <br /> Operational Status Tire Type <br /> Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that app <br /> ly) <br /> Tire Count (Whole/PTE) <br /> 7 Q Active Q Passenger Q Generator Q Outdoor <br /> Latitude D Q Closed Q Altered <br /> GPS ���..--„� • �_1^��L�_ � Q Hauler Q Indoor <br /> D Q Inactive Q Truck <br /> Longitude – Q Planned Q OTR Q End-Use Q Container <br /> Business r ype (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q1 Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / <br /> m � Ell <br /> Q Q 1 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> § 1 Submittal Comprehensive Tripogrhia 0 days i <br /> (Required for NOV or EXT) <br /> Q Q <br /> 0 14 CCR§ 18459.3 Retention of Comprehensive TPo9fo3ye <br /> rs <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred r CIWMB Enforcement <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 Q In Compliance - No Violations <br /> Q O (Other: § <br /> Comments r <br /> e � <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X �, 5 , ',(�' ¢_ 1 2 662081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />