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4 <br /> Waste Tire Su Y & Inspection Reportspection Report Number <br /> State of California <br /> -CIWMB181(New04104) Survey Form - Page 1 ! 3 _-..-_1 0 14 7 9 3_ _! <br /> " -California Integrated Waste Management Board <br /> AK A- Surve BLUE OR BLACK INK PEN <br /> 1111111111111m, 11 Sim <br /> TPID- ' t / Inspection Type (Fill one) <br /> l: .kite Suffix: I c�� - [dZ <br /> Q Routine O Re-inspection Q Referral Q Observation <br /> Local f If Referral,choose referral type(Fill one) <br /> Identifier: ¢. 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> ..moi., r, <br /> k 'gusiness or Facility Name Inspected By Inspector <br /> ;Physical Address ( --- a_ '- <br /> Street Inspection Date <br /> I Time In Time Out <br /> City State ZIP Code _ <br /> Business Rep Title 0AM : Q AM <br /> Q PM <br /> QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> The itbUnt(Wh016/�"�tE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active d Passenger Q Generator Q Outdoor <br /> Q Closed 0 Altered <br /> GPS Latitude m • u1 Q Hauler 0 Indoor <br /> D Q Inactive 0 Truck I I <br /> Longitude — O Planned 0 OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station O Hauler O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A j HAULING AND MANIFEST REQUIREMENTS <br /> Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 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/CIWMB Enforcement <br /> 0 1 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 0 In Compliance - No Violations <br /> 0 0 Other: <br /> Comments r —" <br /> t " <br /> Inspec <br /> Comments Included`. Q _.. _ -- . .. ,wi7i PEN:IF <br /> , <br /> Business Rep"s Signature Phone Number Inspector's Signature Phone Numbe„ <br /> 62081. <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X I A. I l_ t <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />