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spection Report Number <br /> Waste Tire Say & Inspection Repo _ In <br /> State of California <br /> CIWMB 181(New <br /> Manag) Survey Form - Page 1 $ - 0 66-8 <br /> California Integrated Waste Management Board "... . ...... . ...._.. _..... _ <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business ProfileInsper'IR4� A aa�, , + i�a "ut�_'��.� ���t,".,. �.�� �r.... <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix. I �. 71 , IQj Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> li Identifier: <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> � Inspected By Inspector <br /> Physical Address <br /> Street <br /> � - Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep�i Title 0 AM 0 AM <br /> 0 PM 0 PM <br /> f-_lr <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply)I, (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger , 0 Generator 0 Outdoor <br /> I D 0 Closed 0 Altered <br /> GPS Latitude =-] <br /> I 0 Hauler 0 indoor <br /> D 0 Inactive 0 Truck <br /> LongitudePlanned D OTR 0 End-Use 0 Container <br /> iBflSlhe`� ft� t apply) <br /> 0 New Tire Dealer (1) Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V , A j HAULING AND MANIFEST REQUIREMENTS <br /> ----- 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X ` _ ., ,00 D 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® S <br />