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■ i`` 9 Waste Tire Su . ey & Inspection Repor, Inspection Report Number <br /> State of California <br /> CIWMB 181(NewSurvey Form - Page 1 I 1 - 1127671 <br /> California Integrated Waste Management Board <br /> Part A-Survey_ _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q Inspection Type (Fill one) <br /> Site Suffix: V - j ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �,,, A� If Referral,choose referral type(Fill one) <br /> Identifier: ' SQ �� 6ZX V O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V Inspected By Inspector <br /> P� <br /> Physical A res fizcl <br /> ,,, <br /> fu <br /> _ C Inspection Date <br /> Time In ! Time Out ! C� <br /> Business Rep ( Title r Z Q AM Q AM <br /> n,lt?ut ' hale It' krfs M& I J ®PM OPM <br /> Operational Status Tire Type Business Role Storage Type <br /> f ' <br /> Tire Count (Whole/PTE) 00 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger ® Generator 10 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned ® OTR 0 End-Use 1 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 Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder I* Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> j V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O 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 1 O Other: § <br /> Comments A J 1 _ <br /> Inspection Form Included: Q <br /> Comments Included: Q -- 7K 7_3 <br /> Bus ne s R0s4signature Phone Number Ins o gnature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: )f1 _ 62081 <br /> 11E■ White Copy:CIWMB Yellow Copy:Operator Pink Co y:L ■ <br />