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Waste Tire Su. .ey & Inspection Reporl,, Inspection Report Number ■ <br /> ill State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 11 - 1127950 <br /> California Integrated Waste Management Board <br /> PartA-_Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I� LA ` b Lt S - d 1 ®Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: `)C tyl �t�(�C )� CaVv�1 / Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name � ( Inspected By Inspector <br /> 2 12 <br /> Physical Address <br /> ��-.,��\\ Inspection Date / 1 <br /> �--'` N �� Time In / Time Out [ <br /> Business Rep Title � !� �' 0 AM 0 AM <br /> � 3 � 40 PM <br /> ®PM <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) (Fill all that apply) <br /> 1 1 0 Active *Passenger Generator ID Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer ®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 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 ENFORCEMENT STATUS <br /> V ! A I HAULING AND MANIFEST REQUIREMENTS <br /> �ONoticeOf 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 • 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m / M <br /> Q Q .14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive 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 /> QQ 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 O In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> n el <br /> Inspection Form Included: Q/usin <br /> UtJ"' <br /> Comments Included: ® 4Pinkopy <br /> KesRep's Signature hone Number Phone Number_ <br /> ---- 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect �?` <br /> ■ White Copy:CIWMB Yellow Copy:Operator © ■ <br />