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U1 Waste Tire Su. ,y & Inspection Report nspection Report Number <br /> 1 _ State of California <br /> CIWMB181 <br /> Waste <br /> eManage) Survey Form - Page 1 Il - 1140770 <br /> California Integrated Waste Management Board <br /> Part A-Survey_ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- S , _ Inspection Type (Fill one) <br /> Site Suffix: O 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name -0 - <br /> 0" Inspected By Inspector <br /> �f � <br /> Physical Address 3 A5CJMQS' <br /> 1/ <br /> O Inspection Date , 3 Q / C) <br /> lJ <br /> Time In Time Out <br /> Business Rep TitleO AM O AM <br /> t -5 <br /> tea' 1 � � — ® PM / G ® PM <br /> r i <br /> 1r:g <br /> d—�— ----- - - - Operational Status Tire Type Business Role Storage Type, <br /> Tire Count (Whole/PTE) 7n1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger I® Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS _Latitude - - - — - - - - -- --- -- - — -- <br /> 0 Hauler <br /> 0 0 Inactive I®Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use ®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 Notice Of Violation 0 Extension <br /> 0 0 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 m / m / m <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 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 /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § -- - - <br /> Comments <br /> oe <br /> Inspection Form Included: U' <br /> Comments Included: <br /> usiness Rep's Signature Phone Number spector's Signat a Phone Number <br /> G,� ,� �—(� <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X "� E -X M , �L`111213 1213 62081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy LE <br />