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Waste Tire Suf0ey & inspection Repor' . Inspection Report Number <br /> State ClWM 181(NewCaliforniSurvey Form - Page 1 1 1 0 2 5 8 5 8 <br /> CIWMB 161(Naw 04!04) <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: J 0 -7 -7d ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local <br /> ^VVG If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `11� Inspected By Inspector <br /> O <br /> Prvsical Address r <br /> Inspection Date 0 I C1. I Q <br /> Time In Time Out <br /> Business Rep / Title O AM O AM <br /> 0 PM 0 PM <br /> / Operational Status Tire Type Business Role , Storage Type <br /> (Fill one only) <br /> Tire Count (WholelPTE) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 4D Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive ®Truck <br /> Longitude _ Q Planned Q OTR Q End-Use Q Container <br /> i 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 /> i 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 /> Y A HAULING AND MANIFEST REQUIREMENTS - Q Notice Of 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 Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EX7) <br /> Q IQ 14 CCR§ 18459.3-Retention of Manifest Forms and Tire 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 /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators40 1h 'COIYtpilanCe No V101etlOne <br /> Q Q Other: <br /> comments r-ler,14 tt-4, <br /> /V,C►1a►-- (5 cl, <br /> 1Jo ,. �.--51, Agr f- <br /> .Inspection Form Included: QI <br /> Comments included: Q <br /> Business Rep's Signature Phone Number s ignatur Phone Number <br /> _ ._..... t <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct; . 1ncorrecti� ��a v ��� �l 1��P; �L� �1 2 <br /> While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />