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FORM NO.M-105547-CIWMB M12 1607 '19 987654321 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> ria State of California <br /> CIWMB 181(NewSurvey Form - Page 1 I - 1 0 7 9 4 3 0 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE_ O_R_ B_LACK INK PEN <br /> LBusiness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 � i <br /> - - ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �wt�«�Y� �u✓��- 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V J Inspected B <br /> P y Inspector <br /> c cr kc G <br /> Physical Address 3 ! - � u <br /> Inspection Date <br /> q J Z 3 Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 0 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 /> - - ' ' ® Active 0 Passenger ® Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive ® Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) - - — <br /> 0 New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 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 <br /> _ v A 'HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> r <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> - - Icy, 1" _ ;.,s�cr�4 cfr,_ civ►-'N�s__.e�c� v:�c�i1-in i�}C-C 1z-12 tis 9 3 - <br /> - CZG &vz,4 Xci�—tom -vi c.t,.a. <br /> lal,�PWI-r _cc1'1C4_a-r0 "4161 �- �.� o• _aia/&---r. _;i( G�-G_ , <br /> U4—rcd.- r /o - �u _GSL S r�hrr,�Vic/fo _ , �-t�f �4tt_i'n o►-t <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature_ Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X i�A I.EIXIA M P[L I El I I . 3 <br />