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Waste Tire Survey & Inspection Report Inspection Report Number . <br /> CRVMB 181 <br /> statedCalifornia Survey Form - Page 1 C 8 10 13 12 3 <br /> 781([New DI/OlI <br /> California Integrated Waste Mar ii-t Board <br /> Part A-Survey BLUE Q j" KINK PEN <br /> Business Profile 1 Inspection Details <br /> TPID- ` I 1 _7 I� �1 I - I Inspection Type (Fill one) UV4Vdv-VUUF4-- <br /> Site Suffix: I �I q �/ I 'Q Routine 19 Re-inspection Q Referral Q Observation <br /> Local ��� ( H Referral,choose referral type(Fill one) <br /> Identifier: �� j5? Jam_ Q CHP 0 CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I'' U Inspected By I Inspector <br /> Physical Address <br /> Street <br /> ,,v/-^�� Inspection Data92 <br /> L <br /> agy SrZIP Code Time In J Time Outy <br /> Business/Rep / Title O AM Q AM <br /> 0 PM ---- - - -- � O PM <br /> + Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 10 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f O ®Active ®Passenger 0 Generator ®Outdoor <br /> Latitude O Q Closed O Altered <br /> GPS Q Hauler ®Indoor <br /> O 0 Inactive ®Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair Q Trucking Fleet Q Govemment Q Retreader O Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture O Shredder ®Other L(/(n s <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> O O Other: §,,. f 1 / (� ^ � / J <br /> Comments(D vV/,\, __4-S �^_15 _A9jr�3 pC7.^,c.•— !7 I-'G_ <br /> 64< P glu-/��, -g +ice_. �c;J; o�fi--C/I.7,-Ll--6 /_)L__> <br /> � A�- P .`"A-A'6 <br /> Inspection Form Included,01 ,'/�� <br /> Comments Included: �'^"K �b <br /> Busines_s_R_ep's_Si_gnature Phone Number Inspf6tor's Signature Phone Number <br /> • X� I I 1 I I I I I I I I 1 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAMPLE 1 2 3 <br /> ■ White Copy CIWMB Yellow Copy Operator Pink Copy.LEA " 0 <br />