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c7��soaab;a <br /> port Inspection Report Number <br /> Waste Tire Survey & Inspection Re ■ <br /> Sateu(calilurMa Survey Form Page 1 1 9 - 1 0.7 3 5 8 9 <br /> CIWMB 181(New 04/04) <br /> li(omia Integrated Waste Management Board <br /> Part Ac'-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> + TPID• 7 In Type (Fill one) <br /> Site Suffix: Q 6 y o T O ®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 /> Physical Address <br /> Street <br /> Inspection Date <br /> ������ � <br /> rfC __ P StateIP ode Time In Time Out <br /> Business Rep Title 'm®PM LL] <br /> 'm0 AM <br /> ® PM <br /> o XY -De — -- - -I t - ---- <br /> -- - Operational Status Tire Type Business Role Storage Type: <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) I I /i <br /> 7 ®Active Q Passenger •Generator I®Outdoor <br /> ° Q Closed Q Altered <br /> _. GPS Latitude Q Hauler Q Indoor <br /> _.1 I Q Inactive ®Truck <br /> Longitude - <br /> I. F .1- � L H Q Q Planned Q OTR End-Use Q Container <br /> Business Type (Fill all that apply). <br /> Q New Tire Dealer Q Auto Repair 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 BEN MRS--EMENT STATUS_ <br /> y q HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Vio anon Q Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration)Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / IE <br /> Q 0 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 (Require-fo 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 ®In Compliance - No violations <br /> Q Q 1 Other: § <br /> Comments ) <br /> Inspection Form Included:Q Ile <br /> Comments Included: <br /> Q <br /> �Business_Rep's Signature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK 1EVAIMIPILIE1 1112131 <br /> 62081 <br /> ■ White Copy.CIWMB Yellow Copy:°peralor Pink Copy:LEA ® ■ <br /> I - _ <br />