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030$0040031 <br /> eon <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> r4 CrwM1 181(NCalifofnia Survey Form - Page 1 d 6 - 1 0 1 9 4 6 8 <br /> CIWMB 181 Waste <br /> ew 04104) <br /> CalKornia 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 /> 1 <br /> Site suffix: 3 d 6 1 4 1 -7 IS71 [J�] ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: L -TouC��w►� Q CHP Q CIWMB .Q Complaint -Q Educational Visit Q Other <br /> Business or Facility Name 1 <br /> Inspected By Inspector <br /> -3 _ ^ <br /> Physical Address 9 / o I /1►� ss L3ceiN�h.� <br /> Street <br /> Inspection Date <br /> � _ , gszyz <br /> fly <br /> ly StateIP Code Time In _ Time Out <br /> Business Rep Title O AM AM <br /> QPM ED:EEI OPM <br /> N_,,uX- �"Mo SfnG,V_' - _ .. - ----.---; Operational Status The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) .(Fill all that apply) (Fill all that apply) <br /> '�/ <br /> e ®Active Q Passenger Q Generator Q Outdoor <br /> I i I O Q Closed Q Altered <br /> GPS Latitude II II � I � Q Hauler Q Indoor <br /> . _ � I.- !_ _d i-_� O Inactive ®Truck <br /> Longitude - I -- i__-.-I O Planned Q OTR O End-Use Q 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 /> 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 ENFORCEMENT STATUS <br /> V , A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> O ! O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O. PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data m /m / d <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMB Enforcement <br /> Q O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> O O Other: § (- <br /> Comments -4t." � �} <br /> lCa �K.- cw <br /> Inspection Form Included:Q X <br /> Comments Included:Q '�'�� 'ea 8 b 6 2 3 <br /> Business-We—Ws Si natu Phone Number —Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: (� E X A M P :LX A P L E�1 i2 32 3 ■ <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA <br />