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Waste Tire Su. ,iey & Inspection Repori Inspection Report Number <br /> CWMBCIWMBB 181(New <br /> New 04!04) <br /> california Integrated Waste Management Board Survey Form - Page 1 1 1 - 1014 89 9 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TpID- / Inspection Type (Fill one) <br /> 6 <br /> Site Suffix: ` �- ?j , 0 Routine le Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: y 0 CHP 0 CIWMB 0 Complaint 0 Educational visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Inspection Date I O 7 (� S <br /> Time In Time Out <br /> Business Rep t Title O AM O AM <br /> O PM O PM <br /> �DCGD W <br /> �,r <br /> CJ � v — <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) t (Fill all that apply) <br /> r t * Active 0 Passenger Generator Outdoor <br /> a 0Closed 0 Altered f <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude – 0 Planned 0 OTR 0 End-Use i 0 Container <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 JI <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection O Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS mµ , <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 1"xtanion <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires j <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline I <br /> 0 0 PRC§42956 -Registration/Decal in vehicle If <br /> 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Data <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB ' <br /> 0 0 (Required for NOV or EXT) <br /> 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 3 <br /> O 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred f4IVYM8 Enft;rR9lti ltd, <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> —^ 77M kip}. <br /> 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> tcf Ct�Inptlmtlgr� <br /> 0 0 �Other: § <br /> Comments 7 i f ) 44 <br /> 3-- �`os • �ti�G¢-r-JJ I s �--�,�.Q,'ll� , ��.: 1 � o S -- r� t�9 0(� <br /> D V , <br /> ,Inspection Form included n _ /J / /LZ% 2q <br /> Comments Included: 0 - - <br /> Business Rep's Signature Phone Numb/erg t s n Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ( Ni E iI M p (� E , 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />