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Waste Tire Su41Py & Inspection Report ispection Report Number <br /> StCIWMB ate <br /> B181Califo(New04/04)rnia <br /> Survey Form - Page 1 t 0 - 1 0 1 0 5 0 4 <br /> California Integrated-Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> i. <br /> i TPID- ( ,l L� .- ,, Inspection Type (Fill one) <br /> Site Suffix: V ® Routine Q Re-inspection Q Referral Q Observation <br /> Local V / I If Referral,choose referral type(Fill one) <br /> Identifier: (? ; ? �V�c C.•tl� ( ( Lt t�.�v O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> If L <br /> Street <br /> i Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> �. r r . r , 0 P 0PM <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 /> O Active O Passenger O Generator O Outdoor <br /> O Q Closed O Altered <br /> W . <br /> GPS Latitude Q Hauler O Indoor <br /> D Inactive O Truck <br /> Longitude — O Planned O OTR O End-Use Container <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government O Retreader Q Dismantler 0 Tire Derived Fuel <br /> O Used Tire Dealer 0 Auto Body O Car Dealer O Collection Q Crumb Rubber <br /> O Service Station O Hauler O Agriculture Q Shredder O 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 /> Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 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 O In Compliance - No Violations <br /> O Q Other: § <br /> Comments r <br /> �tr <br /> -( 1AT ho uI` CC(k-1 11 CA ru , <br /> rct j(_ 0l'"( t-� <br /> > <br /> f19 <br /> e <br /> Inspection Form Include . <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X /;, \/ I:_ < ;A. ; p I L 1 2 3 j 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />