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=H Waste Tire Sui y & Inspection Report Ispection Report Number <br /> :� State of California <br /> CIWMB 181(New nage) Survey Form - Page 1 I 1 - 1140611 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details - <br /> TPID- Inspection/ Inspection Type (Fill one) <br /> Site Suffix: D D le Routine Q Re-inspection Q Referral Q Observation <br /> Local l If Referral,choose referral type(Fill one) <br /> Identifier: �j `" Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name) Inspected By Inspector <br /> Physical Adress <br /> qq ,?7 (^lam <br /> Inspection Date / 0 S <br /> Time In Time Out <br /> Business Rep Title <br /> / 0 S O ® AM AM <br /> O PM ® O PM <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 /> — ' v ® Active ® Passenger ® Generator • Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer ® 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 /> 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 /> O O :PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 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 f CIWMB Enforcement <br /> QLOO <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - <br /> Q14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® in Compliance - No Violations <br /> QOther: § <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: ® —errect: <br /> -- - �Busi Phone Number Inspector's SI ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BAIncorrect: X ,. �/ z X �4 A 2 2 31Yellow Copy:Operator Pink Cop :L <br />