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Waste Tire Surly & Inspection .Report ,ispection Report Number <br /> State of California <br /> Willa CIWMB181(New04104) Survey Form - Page 1 [ 17 - 1 Q 3 7 8 <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: F/I /To ,�"7J o f 2 I Q [10 Routine 0 Re-inspection 0 Referral ® Observation <br /> Local -I� If Referral,choose referral type(Fill one)k. <br /> Identifier: �J 0 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility NameU Inspected By Inspector <br /> 13�a�un,on , TT ?_ I 3 _ o i JJ <br /> Physical Address <br /> P� Et <br /> Street <br /> Date <br /> �ft Inspection ae <br /> n � °l S�o"S v <br /> City State Z!p Code Time In Time Out <br /> Business Rep Title Wyl <br /> L.� ® AM O AM <br /> 1 OPM m ' OPM <br /> i_T 2- _ ` - <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) i Of 0 Q <br /> ®Active ® Passenger ® Generator ®Outdoor <br /> -- T--' - T--!O 0 Closed 0 Altered <br /> GPS Latitude I 0 Hauler Indoor <br /> r-- - -- <br /> 0 Inactive ® Truck <br /> 0 <br /> Longitude – ` ! 0 Planned ® OTR ® End-Use ® Container <br /> 111 <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body 0 Car Dealer ® Collection 0 Crumb Rubber a( 11 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other t_S"rc if hD K&t j"" <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A !HAULING AND MANIFEST REQUIREMENTS Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date I I <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred t CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § / <br /> Comments C,7���5oP_09 �J TW;i . Q.� IT Z, <br /> �� Lq—r7uti 51 k �'i- --`�/�! �nY� ?ly�SCrvJ,g �pF_ Z_ , <br /> Inspection Form Included: <br /> Comments Included: ® ��'1 t �� ' =� `— <br /> Business Reps Signature Phone Number I pector' ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: JEjXjAjMjPT0EJ 111213 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />