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IX <br />- E Waste Tire SU , .y & inspection Report!:. nspetaion Report Number ■. <br />Will <br />State of California -,!� CIWMB181(New 04104) Survey Form -, Page 1 - a. <br />California Integrated Waste Management Board <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile 1'Inspection Details <br />TPID -G Inspection Type (Fill one) <br />Site Suffix: ( 14 1 -713 !�- I Q Routine Q Re -inspection Q Referral <br />Local If Referral, choose referral type (Fill one) <br />Identifier: "" x <br />O CHP Q CIWMB Q Complaint <br />Business or Facility Name Inspected By <br />Physical Address <br />Q^ Observation <br />Q Educational Visit Q Other <br />Inspector <br />Street <br />Inspection Date <br />City State Zip Code Time In Time Out <br />Business Rep Title @,AM ©' AM <br />DE C i 0 PM Ei Q PM <br />Operational Status Tire Type Business Role Storage Type <br />Tire Count Whole/PTE <br />' ° �L�J�.1 (Fill one only) (Fill all that aRPIY) (Fill all that aRRIY) (Fill all that app! <br />Active Passenger (§P Generator Outdoor <br />D Q Closed 0. Altered <br />GPS Latitude m •FF Q) Hauler 0 Indoor <br />D Q Inactive 0 Truck <br />Longitude - O Planned 0, OTR End -Use Container <br />Business Type (Fill all that apply) <br />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 0 Agriculture Q Shredder Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O <br />O <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />O <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Q <br />O <br />14 CCR § 18459.2.1 _ Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 <br />O <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 <br />O <br />14 CCR § 14460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />O <br />O <br />14 CCR §18461 - Manifest.System Requirements for Waste Tire End -Use Facilities <br />O <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />n <br />In <br />Other: § , <br />Dismantler Q Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date <br />m/m/m <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />O In Compliance - No Violations <br />Comments - J i 1 T, j l ! -�=- : I I r_, - A.) <br />J <br />t 5 �_ 1J c t(' ' 1� t` _ ✓ c . �..•.> ' t ' - _ 1.� r. F , j .. ( ' <br />s <br />nspection Form Included: 0j <br />Comments Included: 0- - <br />Business Rep's Signature Phone Number Inspector's Signature Phone Number <br />I�!797JI] <br />INSTRUCTIONS ON BACK Correct:* Incorrect: W �. ,hR P a- S' 1,213 62081 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA ® ■ <br />