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■ NU <br /> Waste Tire.S & Inspection Repospection Report Number . <br /> State of California CIWMB181 <br /> Waste <br /> eManage) Survey Form - Pag;-\ 1 � 8 - 3 0 0 6 -1 � 3 <br /> California Integrated Waste Management Board <br /> Part A- Survey , BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ff Inspection Type (Fill one) <br /> Site Suffix: O �—. t _ �'Routine - '0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: h 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected B <br /> P y Inspector <br /> Physical Address — <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM _ _ <br /> .e 0 AM. <br /> J t7 t:J <br /> ® PM -} � '� � QPM I <br /> Operational Status Tire Type Business Role Storage Type • <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active � Passenger Generator f � g 0 :Outdoor <br /> GPS Latitude m • D 0 Closedl 0 Altered <br /> 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned. 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer O.Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A i HAULING AND MANIFEST REQUIREMENTS <br /> 0 O PRC§.42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 1 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements i Date / <br /> OO 14 CCR§18459.1 (a)(b)(c) Tire Program ID Number from CIWMB m m m <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days' (Required for NOV or EXT) <br /> 0 — - -0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years _._... .. - ..... . ---- ­­- <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> W 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealer's or Waste Tire Generators O <br /> 0 Other: § In Compliance - No Violations <br /> 0' <br /> Comments .. t <br /> t_Aj <br /> \ `z \\�.. ? Vl �t `_J�� If�y_( y J�'� I.. S.. �1�LqL <br /> v.. C t: �'tJJ ` i <br /> Inspection Form Included: ; <br /> Comments Included:0 - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ,,INSTRUCTIONS ON BACK Correct:0 incorrect: } – V .A'M LL 1,P 2 3 62081 <br /> — ® ■ <br /> White Copy:CIWMB , Yellow Copy:Operator Pink Copy:LEA <br />