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Waste Tire Sur0_y & Inspection Report inspection Report Number <br /> State B California Survey Form - Page 1 �1 - 0 Z V -S ` <br /> a CIWMB 181(New 04104) <br /> lifornia Integrated Waste Management Board _ _..... <br /> Part A- urve BLUE OR BLACK INK PEN <br /> TV'RIM <br /> TPID- Inspection Type (Fill one).,__ <br /> Site Suffix: _ — Q Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CIWMB Q Complaint O Educational Visit O Other <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> Physical Address <br /> t � <br /> Street <br /> Inspection Date Ej / EE] <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> 0 PM 0 PM <br /> N Operational Status Tire Type Business Role <br /> (Fill one only) (Fill all that apply), (Fill all that apply) <br /> Tire Count(Whole/P7E) LLJ <br /> t✓ (D Active O Passenger Q Generator � j `w sr <br /> . _ O <br /> Latitude Q Closed 0 AlteredA�t <br /> GPS s,M �i. ^�., O Hauler <br /> 0 O Inactive 0 Truck <br /> Longitude – 0 Planned 0 OTR O End-Use 0 Container <br /> O New Tire Dealer Q Auto Repair S Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer Q Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation Q Extension <br /> 10 ® PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> 0 1 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m m <br /> 0 Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> 0 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: o� x <br /> Comments Included: Q <br /> ,w. <br /> Business Rep's Signature Phone Number inspector's Signature Phone Number <br /> -- <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X A�- E'X 62081 <br /> ■ <br /> White Copy:CIWMB- ■ <br /> Yellow Copy:Operator Pink Copy:LEA <br />