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■ ''`'£c Waste Tire Shy & Inspection Repo Lp�io.�R ��37 <br /> sial State B CaliforniaSurve Form - Page- 1 <br /> CIWMB 181(New 04104) � <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - E51 Inspection Type (Fill one) <br /> Site Suffix: l-� <br /> Routine 0 Re-inspection Q Referral Q Observation <br /> Local �. .r �„� - II If Referral,choose referral type(Fill one) <br /> Identifier: r. c'��.�,., t-j ,' O CHP Q CIWMB 0 Complaint Q Educational Visit O Other <br /> Business or Facility Name — — -�- — — <br /> Inspected By . Inspector <br /> Physical Addtess <br /> Street % <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 Am 0 AM <br /> m ' m O PM m ' m O PM <br /> t—/ Operational Status Tire Type Business Role Storage Type <br /> Tire CountWhole/PTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ( ) Active /'�.:Passenger Q Generator Outdoor <br /> O Q Closed _ 0 Altered <br /> GPS Latitude m Q Hauler 0 Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - O Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel . <br /> Q Used.Tire Dealer Q Auto Body O Car Dealer O Collection O 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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - - - - --- Q Notice Of Violation Q Extension <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of.Tires <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90.days (Required for NOV or EXT) <br /> Q Q 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 t CIWMB Enforcement <br /> i <br /> 0 O 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 <br /> Ql In Compliance - No Violations <br /> 0 O Other: § <br /> Comments G� -•>75 �, f"C ,;, �- �� �J — � �L� � ��� f/ 7 " 4 <br /> I <br /> i— <br /> ,� Vi_>l, �-a_ <br /> Inspection Form Included: 01I _ - <br /> Comments Included: 0 _ - <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X)w U E��: .AM P d E 12 3 62081 <br /> ■ a�— ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />