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im <br /> Waste Tire SL ey & Inspection Repor Inspection Report Number <br /> State of California <br /> Survey Form Page 1 1 0 2 7 8 <br /> CIWMB 181(New nage) ,. <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: •b 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S __.,` �OCHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v/`yr^ <br /> Inspected By inspector <br /> Physical Address �j 0 t <br /> may' _ <br /> Inspection Date C, <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O 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 /> D • Active Q Passenger ®Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Q Inactive is Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q 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 1 A I HAULING AND MANIFEST REQUIREMENTS <br /> O Q - Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle m <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§ 18459.1 (a)(b) (c)-Tire Program iD Number from CIWMB I I I <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days {Required for NOV orEXT <br /> 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 Fk6fsrrcd 1 CIWMB ,EnforcOnent <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ITI !y'iQRtptlancd No Vipltt ipns <br /> Qom_Other: § _.... <br /> Comments <br /> No \i"u�� A,Ar� 6M.Cef-A yaCA1\1')l%AN XA -.9 V-1V <br /> tkea%�Y\ �'x> Yr_�4.> C. Plej 'nu� - A C-1 4Ae— <br /> M4 9-4CM+ rAAAJ�e4' t& I ^Jidlte4�- W tc4t'ov�"�r- I-rnoek-/. <br /> Inspection Form Included: Q. /G <br /> Comments Included: Qom— - � 7ta /$ <br /> ne s Rep's Sign e P e Number Phone Number <br /> INSTRUCTIONS ON CK Cnrratr , Ifi1D ; �XP`-� -1 i Z 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />