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Waste Tire Surly & Inspection .Report ispection Report Number <br /> State of California <br /> t CMMB181(New 04/04) Survey Form - Page 1 1 7 - 1 41 3 7 5 8 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- w Inspection Type (Fill one) <br /> Site Suffix: ' O .� (� 12 - Q Q Routine Q Re-inspection Q Referral ® Observation <br /> Local -r^ If Referral,choose referral type(Fill one)•t. <br /> Identifier: _ +D Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name vU Inspected By Inspector <br /> t3rayt,�,oM, Tr'Ye ` t <br /> Physical Address 3 V <br /> Street / / I <br /> I 0 A- <br /> L S20S Inspection Date <br /> City State Z!P Code Time In Time Out v <br /> Business Rep Title AM 0 AM <br /> All 1 I 1 O PM m O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) t i t Q j 010 <br /> ® Active Q Passenger ® Generator ®Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude I Q Hauler Indoor <br /> 10----� —� Q Inactive ®Truck <br /> Longitude - i Q Planned ® OTR ® End-Use ® Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer ® Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other I Sb(A le, <br /> l <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A ;HAULING AND MANIFEST REQUIREMENTS 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 in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / <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 O 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 t 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 /> Q Q Other: <br /> Comments ,�--�� --�'1 , i/ 7 <br /> 1 � iJ 1 <br /> Inspection Form Included: f® <br /> Comments Included: 4"r-01 q �r !Sy0 <br /> husess Reps Signature Phone Number 91p4,�,t+ol9,,ture Phone Number <br /> thAF L <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A S111213 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />