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09152040221 <br /> =P , Waste Tire Su`*ey & Inspection Repor ,, Inspection Report Number <br /> State of California <br /> CIWMB 181(Now 04104) Survey Form - Page 1 11 - 1088489 <br /> Califomla 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: ,— Routine Q Re-inspection Q Referral Q Observation <br /> LocalI..Jl.l� t �; If Referral,choose referral type(Fill one) <br /> Identifier: tM _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or,F,acillity Name 111 Inspected By Inspector <br /> Physical Addres 3 1 i I i I J L&( _ <br /> Street ( � Inspection DateI1� <br /> E041 <br /> 1 <br /> QCl.y ( Q `�' ' Stat. Ll�Ccoe Time In Time Out�f J <br /> Business Rep Title I i - — -- (10 AM ---T— ---; AM <br /> 1 I--� I -' i Q PM I i I to Q PM <br /> �c,v� s_ -- Q�S0r, G _ _ <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) .(Fill all that apply) <br /> 0. <br /> e Active Passenger 10 Generator S Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive • 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 0 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 L <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler.and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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. C-ompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 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 (Required for NOV or EXn <br /> Q IQ 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q IQ 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/C-IWMB 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 1 0 1 Other: § -- ----- - - <br /> Comments Q� 1z <br /> Inspection Form Included: Q <br /> Comments Included: QI"jf�",�- - <br /> uslness Rep's Signature Phone Number Inspe ors ignature one Number <br /> INSTRUCTIONS ON BACK CorrectM Incorrect: E X A M P L E 11 [2 3 62081 <br /> WhiIe Copy CI Ye IoW Copy.Operator Pink Copy LEA <br />