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Waste Tire SUz & inspection Repok _ Inspection Report Number <br /> - <br /> State of California - <br /> ies= <br /> CIWMB 181(New 04104) Survey Form - Page 1 1 8 - 10 1 .4 8 7 <br /> •\ California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- p, / Inspection Type (Fill one) <br /> Site Suffix: Z 1 5 j 1. (61 Routine Q Re-inspection Q Referral Q Observation <br /> Local -. If Referral,choose referral type(Fill one) <br /> Identifier: `�� _ G r O CHP O CIWMB _Q Complaint Q Educational Visit O Other <br /> Business or Facility Name r — - -`-`— <br /> Inspected By —Inspector <br /> I r I � <br /> Physical Address J � <br /> Street <br /> _Inspection Date <br /> City State ZIP Code Time In Time Out <br /> —10 PM <br /> Business Rep Title m O AM O AM <br /> : F1 [IT m QPM <br /> Operational Status Tire Type Business Role Storage Type ' <br /> Tire Count <br /> (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active 0 Passenger Q Generator 0 Outdoor <br /> O (5Closed Altered <br /> GPS Latitude m • Q Hauler 0 Indoor <br /> O. <br /> 0 Inactive 0 Truck <br /> Longitude - O Planned OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer O Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer i Q Collection io Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture i Q Shredder Q Other I I <br /> Part B - Inspection of Waste Tire Dealer, Gene`r'ator, Hauler and End-Use Facility ENFORCEMENT STAT_U_S <br /> LING AND MANIFEST A REQUIREMENTS O Notice Of Violation Q Extension <br /> O PRC§ eTire Hauler Re9stratoand raps ort of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m �' <br /> O 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB " <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EX7) <br /> O O 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 /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> Q 1 O 1 Other: §+ <br /> Comments <br /> ID <br /> Inspection Form Included: C <br /> Comments Included: - - - _ _.._ - ,:.. = - ..- - - <br /> Business Rep's Signature Phone Number In ector's Signature Phone Number <br /> r�;1 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: g) ENS A M P I� 1 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> - r - A <br />