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i <br /> Waste Tire Sur :y & Inspection Report Inspection Report Number <br /> �-- State of California <br /> SurveyForm - Page 1 ( 1 - 1 0 1 0 1 9 0 <br /> -I CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` I I - Inspection Type (Fill one) <br /> Site Suffix: / / <br /> Q Routine Q Re-inspection Q Referral Q Observation <br /> Local ' If Referral,choose referral type(Fill one) <br /> Identifier: F Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Inspection Date c <br /> State ZIP Code Time In Time Out <br /> Business Rep J Title 0 AM 0 AM <br /> I I ( 0 PM I I I ' QPM <br /> 0EL,)Y(f <br /> I Operational Status The Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whale/PTE) <br /> Q Active Q Passenger Generator Q Outdoor <br /> Q Closed Q Altered <br /> Latitude I . <br /> GPS Q Hauler Indoor <br /> In Q Truck <br /> Longitude — Q Planned O OTR Q End-Use <br /> at apply <br /> Q New Tire Dealer Q Auto Repair ®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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 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 Q Referred/CIWMB Enforcement <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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> } r <br /> I`(�.�_l��Cf i � (i: _.� i ( �i1, ; _ '�`•(�� r �,����T�LI r 1 (���` �Ir� �'>d � � �'t <br /> r ;, 11_i_1 <br /> r.10 CIt1l) r� ,%'% rLs; f�Clr Se .s +4,11�rr "fr:<�i< rc✓W`7'1'l i <br /> Inspec�m Included: Q - <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X y, A: MI P I L I EI 1112 13 I 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� <br />