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Waste Tire SuAy & Inspection Report• Inspection Report Number <br /> State:tied CIWM 181(Now <br /> Survey Form - Page 1 i - 1 0 Z 7 <br /> CIWMB 181(NeM nage Y J <br /> California Integrated waste Management board <br /> 15 <br /> 'art A-.Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � � � Inspection Type (Fill one) <br /> Site Suffix: 'Routine Q Re-inspection Q Referral Q Observation <br /> Local 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 <br /> �j/� �I' Inspected By Inspector <br /> Physical Addre�e <br /> Inspection Date / l I 0-5 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply). <br /> Tire Count (Whole/PTE) ,p <br /> 11 Active Passenger 0 Generator Q Outdoor <br /> Q Q Closed Q Altered <br /> GPS Latitude I®Hauler ®Indoor <br /> O Q Inactive •Truck <br /> Longitude — Q Planned Q OTR o End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station ® Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A. HAULING AND MANIFEST R0.0IREMENTS xtenslon � <br /> o ; o ; <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires o Notice Of Violation Q E i <br /> 0 o PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q o PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB I l I 1 1 <br /> Q o 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requlmd forNOVorEXT) j <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Ry114pvd I,CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> o 0 Other. § In 111110 oa Nie Violations - <br /> Comments <br /> ��`�T`, l�laS �ci✓ 77>//> <br /> gap,.- a icor, & /� <br /> �it f3 i s <br /> Inspection Form Included: O <br /> Comments Included: <br /> Business Rep's Signature Phone Number 1 ct a Phone Number <br /> INSTRUCTIONS ON BACKt?tf�tJIt##�4�'#' r � 1 A h�h��'I�L j 1_ r3� 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />