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■ Waste Tire Survey & inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New 04104) Survey Form-- -Page 1 12 - 101368 7 <br /> California Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details. <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: T o Q 8 ® � ,Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: QyL - Q CHP Q CIWMBQ Complaint Q Educational Visit Q Other <br /> Busine or Facility Name _ <br /> Inspected By Inspector <br /> Physical Addregs 3 <br /> Inspection Date <br /> —oL <br /> Time In Time Out <br /> Business Rep Title ®AM 0 AM <br /> y30PM / l 0 P <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) � <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> > S Active ®Passenger. 0 Generator ®Outdoor` <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned ®OTR Q End-Use Q Container <br /> 1 <br /> Business Type (Fill all that apply) <br /> 0 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 <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORGE1 #TSA#tJS <br /> a211' 'At 6 ,MlAt iFES—Y-cQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension, s= <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 <br /> Q O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q O 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 In Compliance = No Violations <br /> Q Q Other: § � .• i <br /> Comments f"Alw1ke JN1°«-&'0107A f �� � e w­j <br /> C1 r4 cye- <br /> Inspection Form Included:O .�SJ_13 <br /> Comments Included:Q <br /> Business ep"s Sig at re Phone Number . Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> t7i6290104.07.44 <br />