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== Waste Tire Survey & Inspection Report Inspection Report Number <br /> :>><. <br /> State California Survey Form Page 1 l .1 0 2 5 7 4 $ <br /> CIWMBB 181(New 04104) � <br /> California Integrated Waste Management Board <br /> Part A. Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- � .� 3 � � / � _ � � Inspection Type (Fill one) <br /> Site Suffix: b 0 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 By Inspector <br /> PfSysical Ad ress <br /> Inspection Date 3 1 a I v -15 <br /> c } <br /> 55,33Z <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Operational Status! Tire Type Business RoleStorage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 ' ® Active Q Passenger Q Generator Q Outdoor <br /> 0 Q Closed Q Altered � <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q inactive Q Truck <br /> Longitude _ Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q DismantlerQ 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 ENFORCEMENT 3T, 1 <br /> I V A i HAULING AND MANIFEST REQUIREMENTS T <br /> Q Notice Of Violation Oitxtiliih <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / <br /> § 14 .1 (a)( )(c)- re Program Number from <br /> Q � 14 CCR 859bTiPID NbfCIWMB t <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Regained far NOV pr pGTf <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> I r _ <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Ref0rredj4.NVMr3r <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 <br /> in 0.4lnpIlance • Ntf 1/ialtt(afti�;, <br /> Q : Q Other: § _ r <br /> Comments <br /> �Inspectlon Form Included: Q r� - <br /> Comments Included: Q r <br /> Business Rep's igna re Phone Number a ure Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: �t !Jl P Lj 1 Z 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />