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sYa�. <br /> Waste Tire Sulk & Inspection Repor*spection Report Number ■ <br /> _State of California T i <br /> 'CIWMB 181(New 04104) 1 1 - 1088303 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 Inspection Type (Fill one) <br /> Site Suffix: �� ' ( 1 to I 1LO 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local .-- r If Referral,choose referral type(Fill one) <br /> Identifier: �rt �h''t � �l. �U l:I h1 r .t 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ` Inspected By Inspector <br /> 1 <br /> n % I <br /> Physical Address <br /> Street 1� <br /> Inspection Date <br /> 1 "L tin 1 <br /> State ZIP Code � Time In Time Out <br /> Business Rep Title ii � � 0 AM � � >� Q AM <br /> 0 PMJJJ"' 0 PM ` <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply)1 (Fill all that apply) (Fill all that apply) <br /> Ot Active 0 Passenger Q Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude �-_`� 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude [��� ��_D 0 Planned 0 OTR 0 End Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair E.; 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 /> Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> - — --- --- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> I — 0 Notice Of Violation 0 Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 / FTI / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB FT1 <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 O -- -- -- -- _ <br /> 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 /> 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 /> r^ <br /> Comments )•� (�,- 1 ���� �� V L' � �/1 i i � (- i t 1 ; <br /> r <br /> I <br /> Inspection FormIncluded 0RIP00*00 W "rud <br /> 0 i Rep's g •t Phone Number ----- 1 p <br /> Comments Inc:uded: <br /> Business Re s Signature / Ins ector s Si natur <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: �,. / ;,My 62081 <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy:LSA, <br />