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FORM NO.M-105547-CIWMB M12 1607 519 987654321 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> LGIm <br /> State of California I - -7 <br /> CIWMB 181(New 04104) Survey Form - Page 1 in. 1/ <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- y - Inspection Type (Fill one) <br /> Site Suffix: 3 5 v 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� ¢ ,.�� — Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �drssPhysical <br /> '3i3CA - <br /> Inspection Date 0 v ;7 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> * PM ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 5 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � 4 <br /> ®Active Q Passenger to Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned • OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 /> -- -- -- -- or, <br /> Part B- Ins Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> HAULIp Y <br /> NG AND MANIFEST REQUIREMENTS <br /> ® Notice Of Violation Q Extension <br /> Q QPRC§ tereHauler Registration and of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 10 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance No Violations <br /> Q Q Other: § <br /> Comments <br /> 'fay 3 j • hr .F <br /> FrccK.o r�•l�� <br /> i N <br /> Inspection Form Included: Q (-ZAL- <br /> yob�T <br /> Comments Included: Q <br /> smess R 's Si tun Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS Co ect: , Incorrect ,+ �T�r I 62081 <br /> �/ E F � 3 <br /> wnitP (..lwMR Yellow Coov:Ooerator Pink Copv:LEA <br />