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E Waste Tire Su 4, . y & Inspection Report I" <br />nspection Report Number <br />aea . <br />asa: State of California <br />M �I 6 <br />CIWMB 181 (New 04104) <br />-California Integrated Waste Management Board Survey Form -Page 1 •Q Q 3 3 <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID -' Inspection Type (Fill one) <br />Site Suffix: 1 01 (41___11iE - <br />- -`� [E] Q Routine Q Re -inspection Q Referral Q'� Observation <br />Local`�� If Referral, choose referral type (Fill one) <br />Identifier: _ �.7 ��� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name — — <br />Inspected By Inspector <br />Physical Address _,z ct' <br />Street <br />Inspection Date / ^ i / <br />City State ZIP Code Time In Time Out <br />Business Rep Title AM )),-:AM <br />Tire Count (Whole/PTE) ❑ f j <br />GPS Latitude LLI - IL�I I Ia <br />r I 1 10 <br />Longitude - <br />L= <br />C' <br />! , CPM 'I S VPM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />Q' Active <br />@ Passenger <br />@ Generator <br />Q Outdoor <br />Q Closed <br />Q Altered <br />Hauler <br />Q' Indoor <br />Q Inactive <br />Q Truck <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader <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 <br />V A HAULING AND MANIFEST REQUIREMENTS <br />Q PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q Q PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q Q PRC § 42956 - Registration/Decal in Vehicle <br />Q Q 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q Q 14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Q Q 14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />Q Q 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 <br />Q .0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q Q 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />01 Q 1 Other: <br />Comments ►� C a a C .�Gi �� ; n (� ;c �1_ <br />i e 1 t <br />/!' <br />Dismantler () Tire Derived Fuel <br />ENFORCEMENT STATUS _ <br />Notice Of Violation Q Extension 1 <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred I CIWMB Enforcement <br />Q In Compliance - No Violations <br />Inspection Form Included: Q <br />Comments Included: - <br />. Business Rep's Signature Phone Number Inspector's Signature Phone Number <br />, 62081 <br />7CV) <br />INSTRUCTIONS ON BACK Correct:Incorrect: )E *�,�M.L P S' 1� E <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA ® , <br />