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= o;_ Waste Tire Survey & Inspection Report ..InspectiShVeUMAI? <br /> 7H State of Califomia <br /> CIWMB181(New Manage) t Survey Form - Page 1 1 3 - 10 7 9 4 7 3 <br /> California Integrated Was[eManagemenl Board ' <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i Inspection Type (Fill one) <br /> Site Suffix: 1 3 i 3 ® ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> U..vy P Y Inspector <br /> Physical Address vv p <br /> I Street <br /> Inspection Date Q 3 6 6 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title : F1 <br /> O AM 0 AM <br /> ILj 1OPM LL :m O PM <br /> Operational Status Tire Type BusinessRole Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> �O Q Closed Q Altered <br /> GPS Latitude ; Q Hauler Q Indoor <br /> - O ®Inactive Q Truck <br /> I Q Planned Q OTR Q End-Use Q Container <br /> Longitude <br /> - I- ISI Z� <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 I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VI A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 1:11 / 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 /> Q Q Other: § <br /> Comments <br /> ��_�,-�—c.'los�ho�.�r—no�r�:-1'✓us/c—�'Ks-.—�C:t�/'_P-/L��cep,/ <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number nSpector's Signa ure Phone Number <br /> 62081 <br /> ■ INSTRUCTIONS ON BACK I Correct:* Incorrect: (� 11 EIXIAIIMIP I LFeFTi 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />