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Waste Tire Su ey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 1 9 7 9 4 4 7 <br /> California Integrated Waste Management Board <br /> Part A-Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: (Q t IS Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: G�n�Q �(N f1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name , Inspected By Inspector <br /> Physical Address 3 I 1 - 0 j e" <br /> Inspection Date I / )— 6 <br /> Time In Time Out <br /> Busines Rip�1 L'W tr Title A1 M} <br /> l in Sl. t ` I O PM ` O PM <br /> v--(1 1,� i� �C�Ml 11cr� 1 f►(� l, <br /> d-- 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 /> Is Active Q Passenger Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude — Q Planned Q OTR Q End-Use Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 /> 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 / IT] / 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 /> Q O 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 In Compliance - No Violations <br /> Q Q Other: § <br /> CommentsL I <br /> u74.S n4ejA f• <br /> f o S b o_.,,_g rj�C l) )Cx,f p <br /> Inspection Form Included: Q <br /> Comments Included: ® - Z(A - '4W22X'1Z <br /> Aus, ess Rep's Signature Phone Number Inspe ZSgnature one Number <br /> __ ---- ----- �- 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X l 1/I C A- 1 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink till"" <br /> ® ■ <br />