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spection Report Number <br /> Waste Tire Suf .y & Inspection Report <br /> State of California <br /> LxS <br /> Ii <br /> CIWMB 181(New Survey Form - Page 1 11 1140607 <br /> California Integrated Waste Management Board — <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> 1Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: S J Q ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: YL,�, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> --- -- <br /> Business <br /> -or Facility Name Inspected By Inspector <br /> Physical Address 3 - 4w <br /> Inspection Date f L S a <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> / 0 aZ a G ® PM d 2 S_ ® PM <br /> - -- i <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 /> ® Active ® Passenger ® Generator Q Outdoor <br /> -- - t7 � Q Closed Q Altered <br /> GPS Latitude I Q Hauler ® Indoor <br /> Q Inactive Q Truck <br /> Q Planned <br /> Longitude - 1 Q OTR Q End-Use , Q Container <br /> - - I <br /> Business Type (Fill all that apply) <br /> Q 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 /> VV_� A HAULING AND MANIFEST REQUIREMENTS -....._. Q Notice Of Violation Q Extension <br /> ---- --- -- _- <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 /> fQ i 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 /> I <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 /> 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 ® In Compliance - No Violations <br /> 0 1 Q Other: § <br /> Comments - <br /> �' w4r - - <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Buber sine s S nature Phone Numspector'sSignatur_e Phone Number <br /> - - --- - - --- --- 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X "X A," L ��12 3 <br /> White Copy:CIWMB Yellow Copy Operator Pink Co :L <br />