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■ Waste Tire S nspectio,n Report Number <br /> uW & Inspection Repo <br /> State of California ro <br /> 7 1-) <br /> CIWMB 181(New 04104) j <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- <br /> Inspection Type (Fill one) <br /> Suffix:Site Su (j) Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local <br /> If Referral,choose referral type(Fill one)Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Phy- <br /> sical Address <br /> L <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> 0 AM <br /> 0 AM <br /> Business Rep Title E 0 PM 0 PM <br /> E <br /> Operationalstatu S TireYPS Business Role tora§'e'Type <br /> (Fill one only) (Fill all that apply')' (Fill all that apply) (Fill all that apply) <br /> (V Active Passenger (D Generator Q Outdoor <br /> 0 0 Closed O'Alt&6d <br /> Latitude <br /> Indoor <br /> 0 Hauler <br /> : ' <br /> GPS 0 Inactive <br /> Truck <br /> L 0 Planned :,O,OTk ; OE <br /> • <br /> !"44' <br /> Business Type somm <br /> End Use 0 Container <br /> Lon <br /> e <br /> 0 New Tire Dealer 0 Auto Repair (a 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 Q Other J <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V,7A I HAULING AND MANIFEST REQUIREMENTS 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 m / m / m <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 1 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 (D 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 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 <br /> In Compliance No Violations <br /> 0 0 Other: § <br /> Comments <br /> _qj l . �Vi ( i I ��� - - /��111 Tj - i.A �r' � ( f: fLl — ' ( _ <br /> CIA. ?J <br /> 1"(7 i�-,'t'r\ o0a" Y, <br /> 10 <br /> -7 <br /> r 4 <br /> V') <br /> :Inspection Form :Includeo'. <br /> Comments Included: ------- <br /> u <br /> Business Rep s -Phone Number tws S Phone Nmber <br /> 2 3 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: P62081FLfE[ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />