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== Waste Tire Suy & inspection Reportnspectibn Report Number ■ <br /> State of California » <br /> CIWMB181(New 04104) ard <br /> BoSurvey Form - Page-1 L 5 - 1 0 7 4 Z <br /> California Integrated Waste Management <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �) N Inspection Type (Fill one) <br /> Site Suffix: / (� �� V t i �' <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> _ .. <br /> 4_ If Referral,choose referral type(Fill one) <br /> Identifier:' �/1!1 &V? •'7 .(,t{y'( °��q k '„( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> I <br /> Business or Facility Name j i/ Inspected By Inspector <br /> !�.(;�,• � � _ <br /> Physical Address <br /> 1 <br /> Street V <br /> 5- Inspection Date r� <br /> City State Z/P Code Time In Time Out <br /> Business Rep Title 0AM 0 AM <br /> EET 0 PM [1] : <br /> 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) � FTUO(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger Q Generator Q Outdoor <br /> O © Closed Q Altered <br /> CIPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude – FT71 - I I I I I 1 Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 L <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 Q 14 CCR,§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q . Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 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 Q In Compliance - No Violations <br /> Or Q Other: § -r / —_- _-- <br /> Comments i t VI's l� '��C � G'I &f� �i� 0'E t . . l <br /> lid S1 t fU C n ; te) �c'� .� _ -rp/I a fit r✓tS <br /> Inspection Form Included 0 <br /> Comments Included. Q <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK •Correct:� Incorrect: X ( i. ihli 'P' 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />