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�.y Waste Tire Su & Inspection Repo sprion ReTt3 <br /> Number ,M <br /> >:i;�= State of California I/� }�A,CIWMB 181(New 04104) ..� it �i, 8 <br /> CalifornialntegratedWasteManagemantBoard Survey Form - Page 1 _ .� <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID= � f � — � ,� �Inspection Type (Fill one) <br /> Site Suffix: (moi— IL1�/JI (V Routine Q Re-inspection Q Referral Q Observation <br /> Local . If Referral,choose referral type(Fill one) <br /> Identifier: + kr C� 0 CHP Q CIWMB Q Complaint Q Educational Visit.0,Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addre <br /> Sttrrbeett <br /> Inspection Date Q <br /> 7 c, <br /> - i Time In Time Out <br /> City State ZIP Code <br /> Business Re /� Title O AM 0 AM <br /> Ij p m ' m 0 PM ' m <br /> PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ❑1 Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> II II ® Active Passenger 9 Generator Outdoor <br /> GPS Latitude m , O Q Closed 0 Altered Q Hauler � Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — Q Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New.Tire Dealer O 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 O Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A !HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 <br /> 14 CCR§.18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 1 459.2.1 -Submittal of Manifest Forms and Tire Tri Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§ 8 P 9 <br /> 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/CIWMB Enforcement <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators It In Compliance - No Violations <br /> O 0 Other: § <br /> Comments � /1 �•^'��� A � ` <br /> gip ) I S <br /> Inspection Form Included: 0; <br /> Comments Included:01Business Re 's Signature Phone Number Inspectors Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ) V� fX J'A M-1 P 'L E I 1 <br /> k. <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA , <br /> ■ G ■ <br />