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FORM NO.M-105547-CIWMB M12 1607 519 987654321 <br /> L33 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB181 <br /> asteManage Survey Form - Page 1 1 5 - 1 0 7 9 4 8 3 <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: 3 1 0 * Routine Q Re-inspection Q Referral Q Observation <br /> Local // If Referral,choose referral type(Fill one) <br /> Identifier �CL" a..[��►n LCsztwl^� O CHP O CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1111 - -- - —- <br /> Inspected By Inspector <br /> Physical Address - C) <br /> - <br /> Inspection Date C) <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ® PM 6 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 Q Passenger ® Generator ® Outdoor <br /> O Q Closed 0 Altered <br /> GPS Latitude O Hauler O Indoor <br /> O O Inactive ®Truck <br /> Longitude - O Planned Q OTR O End-UseHQ Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair O Trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORGEMENT STATUS <br /> - - - - --- ------ <br /> O O -- 10 Notice Of Violation O Extension <br /> 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 O PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 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 /> - -------------------- _............ . _ <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> Q 0 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 /> 0 0 Other: § - -=:- <br /> Comments nn q <br /> Sys L, 4M VvGw t..pe <br /> Q -�- .3 l�✓YS 6�a 4c � -C�-f {aa�.� �� ►�- �2--(����a-�-�-v S� <br /> Inspection Form Included: Q x <br /> Comments Included: Q ' " - <br /> Business R s Signature Phone Number inspector's Signature Phone Number <br /> ' <br /> INSTRUCTIONS ON BACK Correct: Incorrect-, <br /> ncorrect E1 .A�' PP L. 1 62081 <br /> White CODv:CIWMB Yellow Copv:Operator Pink Copv:LEA <br />