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Waste Tire Sufty & Inspection Report*nspection Report Number <br /> State of California <br /> Y ats <br /> CIWMB 181(New 04104) Survey Form - Page 1LI 4 - 1 0 0 6 5 0 3 <br /> California Integrated Waste Management Board .- <br /> -A- Survey k, BLUE OR BLACK INK PEN <br /> Inspecfiorr betas <br /> r <br /> TRID- _ _ I I + Inspection Type (Fill one) <br /> W <br /> Site-Suffix: <br /> (g) Routine Q Re-inspection Q Referral Q Observation <br /> Local r' If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name j Inspected By Inspector <br /> Physical'Address it r / <br /> Inspection Date <br /> seat EEE IIIA <br /> __�dr <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> LLIJ 0 PM EE 0 PM ' <br /> -��t __s: Operational Status Tire T a Business Role Stora e <br /> P YP 9 Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/ TE) <br /> s (0 Active 0 Passenger `I (P Generator Q Outdoor <br /> rD Q Closed Altered <br /> GPS Latitude m • ��� Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude v Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) n,,. . .• <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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> V <br /> Q Notice Of Violation Q Extension <br /> 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 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I 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 Other: § <br /> Comments <br /> i - C_ <br /> Inspection Form Included: O, <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X � 3 <br /> ■ ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />