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rices; <br />cw <br />Califorrii <br />Part A - Sur <br />Business Pro <br />TPID - <br />Site Suffix: <br />Local <br />Identifier: <br />Waste Tire Sur, & Jnspection Report spection Report Number ■ <br />State of - Survey Form -Page 1 f 7 - 1.0 -3 3 .3 <br />CIWMBB181 (New 04104) ' <br />itegrated Waste Management Board <br />?V BLUE OR BLACK INK PEN <br />insPection JDetails <br />�^�7 _ [�12 Inspection Type (Fill one) <br />M12- <br />A q F 1 / ® Routine . Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />?• Iy -•/ Q CHP Q CIWMB Q Complaint Q Educational Visit .Q Other <br />Business or Facility Name Y— - <br />Inspected By <br />Inspector <br />Service <br />Station Q Hauler Q Agriculture Q Shredder Q Other <br />I <br />I <br />Part B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />0 Notice Of Violation Q Extension <br />Physical Address <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />I 7200 LJdc,- <br />Compliance Deadline <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Street <br />Inspection <br />Date <br />F1 <br />(� <br />Dli li <br />I <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />City State ZIP Code <br />Business RepTitle <br />Time In <br />w AM <br />Time Out <br />0 AM <br />(Required for NOV or EXT) <br />Q <br />�'M <br />0P <br />m'm <br />0PM <br />I I <br />I Operational Status <br />(Fill one only) <br />Tire Type <br />(Fill all that apply) <br />Business Role <br />.(Fill all that apply) <br />Storage Type <br />(Fill all that apply) <br />Tire Count (Whole/PTE) <br />Q <br />i <br />O Active <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0,.- Passenger <br />O Generator <br />O'j Outdoor <br />O <br />Other: <br />Comments <br />O <br />' (K) Closed <br />0 Altered <br />Latitude <br />GPS- <br />. <br />� Hauler <br />0)Indoor <br />p <br />0 Inactive <br />0 Truck <br />Longitude — <br />O Planned <br />0 OTR <br />0 End -Use <br />0.1 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 0 <br />Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body Q. Car Dealer .Q Collection Q Crumb Rubber <br />Q <br />Service <br />Station Q Hauler Q Agriculture Q Shredder Q Other <br />I <br />I <br />Part B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />0 Notice Of Violation Q Extension <br />V ' A . HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date <br />M/M/m <br />Q <br />0 <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 <br />Q <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />(Required for NOV or EXT) <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />Q <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred / CIWMB Enforcement <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />In Compliance - No Violations <br />0 <br />O <br />Other: <br />Comments <br />I <br />et <br />6 -- <br />Inspection Form Included: 0 <br />Comments Included: - - - - ---- — - Agna�ure <br />Business Rep's Signature Phone Number Inspet is Phone Number <br />INSTRUCTIONS ON BACK [Correct: I* Incorrect: )' ',� /. , ,� 112 3 62081 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA . <br />