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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Slate of California <br /> CIWMB181(Now 04104) Survey Form - Page 1 12 - 1 0 0 6 0 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- —7 Inspection Type (Fill one) <br /> Site Suffix: 3 d / (9 Routine Q Re-inspection Q Referral Q Observation <br /> Local _, If Referral,choose referral type(Fill one) <br /> Identifier: LI n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ✓ Inspected By Inspector <br /> Physical Address 9 fiy, • ��CF�r-t s• <br /> Inspection Date © S` 7, 6 / Q S <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) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active ID Passenger ®Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> D Q Inactive ®Truck <br /> Longitude Q Planned Q OTR Q End-Use Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 41 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 ENFOFCMENT STATUS <br /> VI A HAULING AND MANIFEST REQUIREMENTS i � Clf 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. Cor�plllin0` <br /> e Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date Q 6 / Z GI 6 S <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIW MI3 <br /> O O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days t(f 101red for NOV or EXE <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years , <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Qet#rrd YGIw�lB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> "Go!.• No Vlolatlone <br /> Q Q Other: § <br /> Comments /- n <br /> 511� �✓- fby+G�' �..1a5r� --�r�� t r C,t �+"'�rj4+r- �torX <br /> /� 6r �e /►`� /1q 4C <br /> / <br /> in 6 —2 ds, <br /> Inspection Form Included: Q 2C ri /� �/ <br /> Comments Included. cl/ <f / C— <br /> Business Rep's Signature Phone Numbers Ins cto' iW Phone Number <br /> INSTRUCTIONS ON BACK �CArrect:� fncfsrralct� (� v� E' �A �'J4�P;.Ir� �1213� s2oa1 <br /> Entered White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> KS <br />