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t 16 <br /> Waste Tire Su. )y & Inspection Report Inspection Report Number <br /> clate of wml311(New Survey Form Page 1 1 9 - 1 0 2 5 714 <br /> CIWMB 181(Naw 04104) <br /> California Integrated Waste Management Board <br /> Part A--Survey BLUE OR BLACK INK PEN <br /> 1 Buslness Profile Inspectlon Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: fb Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> PhysicalA drs <br /> Inspection Date 0 <br /> Time In Time Out <br /> Business Rep Title Q AM 0 AM <br /> 0P 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (fill all that apply)j <br /> � � <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> � Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 00 Inactive Q Truck <br /> Longitude — Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q 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 I fVkCIl— CQ.?Ct <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ' ENFORCEMENT STATUS <br /> w►tlINEi0REQWIRSMINTSX � T <br /> Q <br /> Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q NOtiaR Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q Q j 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements opts m I m I m <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB 1 I J ! <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV orEX ) <br /> O ; O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> i <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Enforcement I <br /> � <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 <br /> Q Q Other: § � fit �CipiktJ�ICa�Ri t= �a.Vlo1rt1019• -— <br /> Comments <br /> Inspection Form Included: Q <br /> j <br /> Comments Included: Q b 9) <br /> - - I <br /> Pusbinas Rep's Signature Phone Numbe�r}f (� spe�ct a ( Phone Number <br /> INSTRUCTIONS ON BACKltlit' tEt:, ' '"' _J L "L_^_ , L ': 2-L3 62081 <br /> White Copy:CIWM8 Yellow Copy:Operator Pink Copy:LEA <br />