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=I ;. Waste Tire SuAy & Inspection Report Inspection Report Number <br /> /111' Slate of California <br /> n CIWMB 181(NewD/ro ./) Survey Form - Page 1 19 1 0 1 3 5 2 9 <br /> co lifomia Integrated Waste Management Board <br /> Part A- Survey _ �_,..� BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID ` J r� ( I - Inspect Type ( -inp <br /> Suffix:Site Sux: II �"� 21 C <br /> Q <br /> I b Routine <br /> 0Re Re inssection Q Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �^ <br /> � ,� . ��f� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street Q 3 12 I 0 6 <br /> Inspection Date <br /> ( <br /> Cityy Stale ZIP"t T� �Code— Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> m - m0 PM m 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> l 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE)' <br /> ® Active ® Passenger Q Generator ® Outdoor <br /> —� tI O Q Closed Q Altered <br /> GPS Latitude ,4 - _ j LTI Q Hauler Q Indoor <br /> ,D Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR ® End-Use 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 Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler ® Agriculture Q Shredder Q Other I I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> 't/ I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> Q 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 EXE <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!CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> . 0 Q 14 CCR§ 18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators ® in Compliance - No Violations <br /> Q Q Other: § <br /> Comments ' <br /> LA,I�.'11� <br /> Inspection Form Included: <br /> Comments Included: ® µ�f aInspe <br /> _. _, <br /> Business Rep's Signature Phone Number ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: i E 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />