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- Waste Tire Su. y & Inspection Reportaspection Report Number <br /> State ClWM f 81(Nrnia Survey Form - Page 1 I - i 0 0 $ $ <br /> •---, CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile on Details <br /> TPID- L <br /> Inspection Type (Fill one) <br /> Site Suffix: l 0 7 r 0 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 Inspected By Inspector <br /> Physical Address — FTE (_7 <br /> Street <br /> Inspection Dated <br /> hV State ' Z/P Code Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> 0 PM Q PM <br /> t I Operational Status r Tire Type Business Role forage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) ill all that apply) <br /> � _'� , � � ._> � O <br /> Q Active Q Passenger Q Generator Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive :Q Truck <br /> Longitude — Q Planned ',0 OTR ° " Q End-Use Container <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 <br /> 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q 0 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 /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments f <br /> r <br /> Inspection Form Included: Q', <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's r'g"t,1r & Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X A I E X hh A P (� 1112 <br /> 3'', <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />