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Waste Tire Survey & Inspection Report InsPection QUA ARAM � <br /> Stateof181Cal(Ne* <br /> SurveyForm - Page 1 1 8 - 10 7 9 4 5 3 <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- / Z t7 / Inspection Type (Fill one) <br /> Site Suffix: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �/A�t.y Cpry�K lyf Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name O Inspected By Inspector <br /> W <br /> _ Gya4,/f %K �yyl I q q <br /> Physics ddress J / Ll�mc�rtc(ef_(jvei�.�J <br /> $/G _ <br /> Street <br /> pInspection Date <br /> - - - Get <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> ®PM � 'm APM i <br /> -- Operational Status Tire Type Business Role Storage Type i <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O <br /> GPS Latitude ®Closed Q Altered <br /> Q Hauler Q Indoor <br /> D Q Inactive Q Truck <br /> I <br /> Longitude Q Planned Q OTR Q End-Use Q Container <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 I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q, 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 /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 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 Q In Compliance - No Violations <br /> Q Q 1 Other: § <br /> Comments <br /> /ruycf✓44L Lam- J <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> ■ INSTRUCTIONS ON BACK Correct: Incorrect: (� EXAMPLE 1 :2 3 ® ■ <br /> White Copy CIWMB Yellow Copy.Operator Pink Copy LFA <br />