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Waste Tire lturvey & Inspection Report <br /> Inspection Report Number <br /> State California Survey Form - Page 1 i 9 2 <br /> CIWMBB 181(New <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 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 5 Inspected By Inspector <br /> Physical Address <br /> 1 <br /> MAU <br /> Inspection Date Q �,'L_ 3 �� <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> _ 0 P QPM <br /> v w. 06c_ _ / Q -l - I Status T-y---- Business <br /> -Role Storage <br /> Tire Count(Whole/PTE) (Fi neonly) (Fillhat apply) ( ll all that apply) (Fill althat apply) <br /> f ' •Active Q Passenger ®Generator ®Outdoor <br /> I D Q Closed Q Altered <br /> Hauler Indoor <br /> GPS Latitude D Q Inactive Truck O Q <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 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 ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <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 /> Q Q PRC§42956-Registration/Decal c E ti Vehicle m <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q • 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I 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 /> Other: § <br /> Comments/n _/ �St-f r �IJ�L �7��'_�.-��� ��— ✓�� �I!CS N�7��: -— <br /> /�fGlLV,�'I�. <br /> 44 nw <br /> 1jC45 i7�G�t Iu�t'J` ctcj l% . C.+'' hyf Nd f if Com' IS <br /> InsP eFeg( ae . Q, 953 76?-0— <br /> Business Rep's Signa re Phone Num pe s Signa Phone Number <br /> ILI -. .. _ . - _ 62081 <br /> INSTRUJOWMA ON BACK Correct: Incorrect: E A N.;P L I E 1 2 3 <br /> KB White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />