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I' Waste Tire SL ay & Inspection Report*Inspection Report Number <br /> s. <br /> State California Survey Form - Page 1 13 - 1006535 <br /> CIWMBB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / �f n l Inspection Type (Fill one) <br /> Site Suffix: 7 1 ( v ( Q Routine Re-inspection Q Referral -.' Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP O CIWMB O Complaint Q Educational Visit Q Other i <br /> Business or Facility Name Inspected By Inspector <br /> P ysical tAddress <br /> Inspection Date 0 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 PM 0 PM <br /> —Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply)1 (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) f O O <br /> O <br /> _j o Active 4& Passenger 0 Generator • Outdoor <br /> % Q Closed Q Altered <br /> GPS Latitude 1 Q Hauler Q Indoor <br /> O 0 Inactive ID Truck <br /> Longitude - 0 Planned Q OTR I 0 End-Use Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer A Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler 0 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 0 Agriculture Q Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> j Q Notice Of Violation Q Extension <br /> 0 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying%vth Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Numt;er from CIWMB <br /> Q 014 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 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 Refereed f CIWMB Shforcement <br /> 0 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> �i7yc � <br /> 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Comp lance o Violations <br /> Q 0 Other: § -- <br /> Comments -- <br /> - _ t <br /> Ins ection Form Included: <br /> Q ? <br /> p Comments Included. •I `-" _ _ q00 j✓ <br /> - - - - - - <br /> �!Business Rep's Signature Phone Number In c or's Phone Number <br /> INSTRUCTIONS ON BACK C Correct___Incorrect �`(�j IFE7�FA'hh P 1 Z 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />