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l <br /> i <br /> = ` Waste Tire u, Jy & Inspection ReportState of Inspection Report Number <br /> fornia <br /> LINO <br /> i, CIWMB 181(New04104) + 7 /�'�j /J{ /j� <br /> California Integrated Waste ManageVIntarSurvey Form - Page 1 1 1 - 10v 65 L LPartA- Survey BLUE OR BLACK INK PEN <br /> Business Profile II nsPection Details <br /> TPID- 7 1 _ 1 Inspection Type (Fill one) <br /> Site <br /> Site Suffix: <br /> * Routine Q Re-inspection O Referral J Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP O CIWMB O Complaint Q Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date 0 <br /> Time In Time Out <br /> Business Rep Title / AAM Q AM <br /> O PM O PM <br /> c� Fill one only) Fill all that apply) Fill all that apply) Storage Type <br /> Operational Status Tire Type Business Role <br /> Tire Count(Whole/PTE) ( Y) ( PPY) ( pp y) (Fill all that apply) <br /> ®Active Q Passenger ® Generator 0 Outdoor <br /> Latitude g O Q Closed O Altered <br /> GP$ O Hauler 0 Indoor <br /> O 0 Inactive ® Truck <br /> Longitude; — O Planned O OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair O Trucking Fleet O Government Q Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> O Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q !i PRC§42956-Registration/Decal in Vehicle <br /> Q Q ! 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q 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 <br /> (Required for NOV or DCT) i <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years I "" <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Referred/61144M"13tEnforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities j <br /> Qli Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No>Violation's <br /> 00 Other: § <br /> Comments <br /> �r��U�-�3�5 �2t�nwd•n�l�'.---� �_��or.r\c K�� �~,v�- ��t1�5. <br /> - sins w( yet'- - , - <br /> Inspection Form Included: 01 <br /> Comments Included: QI <br /> -4siness a Signature Phone Number In s re Phone Number_ <br /> INSTRUCTIONS ON BACK Correct _'Incorrect X "V E'x I A-0Mj P E L 1 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />