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sort Number <br /> Waste Tire Sury & Inspection Report pection Rep <br /> Gra:Z.. State of California O y A <br /> i�aa�a CIWMB181(New04104) Survey Form - Page 1 t >< <br /> California Integrated Waste Management Board -- -- -- - - - -- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile kill <br /> TPID- / ! -� =-. NE Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral Q.Observation <br /> Local , �} If Referral,choose referral type(Fill one) <br /> Identifier: � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �7 <br /> Physical Address <br /> c, <br /> Street ll p �l l l _ l <br /> � r t Q � -;--, i Inspection Date <br /> ED] <br /> City _ State ZIP Code Time In Time Out <br /> Business Rep Title } O AM O AM <br /> O PM <br /> [�U <br /> � O PM <br /> LA I Operational Status Tire Type Business Role Storage Type <br /> C (Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply) <br /> Tire Count'( ) � � (J <br /> (0 Active 0 Passenger (D Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude m , �,�, ��s 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> , <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 1 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 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 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 0 In Compliance - No Violations <br /> 0 0 Other: <br /> Comments I�C 6y <br /> {r� C h10 ) ( e c(rre d 0i . hl,; =,i�� Pvl[1 pit 01V i CL "? S (S T C <br /> (}III CV,;I�� '�' �u'�°f�iy-'�� �tv".: hi�X t. � ���� n ,- �( )r >, t � • �� err <br /> Inspection Form included:.0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> - <br /> INSTRUCTIONS ON BACK Correct:® 62081 Incorrect: X �°" - <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA E� <br />