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eia <br /> Waste Tire SLWy & Inspection Repor Inspection Report NumberState ■ <br /> C,WM f 81(New Survey Form - Page 1 1 3 - 10 2 5 3 2 4 <br /> CIWMB 181 New 04104 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR-BLACK INK_PEN <br /> Business Profile Inspection Details <br /> TPID- t r� - Inspection Type (Fill one) <br /> Site Suffix: ?f ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(fill one) <br /> Identifier: CHP <br /> Q Q CIWMB O Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> _ Inspected By Inspector <br /> Physical Address <br /> 3T011V-11 <br /> Inspection Date v <br /> Time In Time Out <br /> Business Rep Title Q AM O AM <br /> Q PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count{Whole/PTE) L�- (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> o ` Q Active J Q Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O ® Inactive ® Truck <br /> Longitude _ Q Planned Q OTR O 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 Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORgEMENTSTAT.kC <br /> I <br /> Vi A HAULING AW MANIFEST REQUIREMENTS Q Notice Of Violation Q fett#Tffn `' <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O i Compliance Deadline � <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> O ! O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date, <br /> Q Q 44 CCR§ 48459.4 (a)(b)(c)- Tire Program 7(J Number from ClL2/M8 <br /> O O ��egU��ert9►rtrs� �i'�' <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years 4 <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Refgrradir VMS-::' <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> ' 4 r .Gill /•J//Li <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire GeneratorsGWIEV jai <br /> O O lOther: § K �� <br /> Comments <br /> Inspection Form Included: Q" <br /> Comments Included: Q - 7 2r1� <br /> Business Rep's $Ignature Phone Number inspe or's Signa ur Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect:-(y ` __}f A N, Pa zR 62081 <br /> Entereu■ y White Copy:CIWMB Yellow Copy:Operator Pink Copy:LE=A <br /> ■ <br /> KEI <br />