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..... <br /> -..........._ _. .... _..._. <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California I 1 1143486 <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> 'art A--Survey -- - - - --- - - - - <br /> Business Profile Inspection Details <br /> TPID- - Inspection Type (Fill one) <br /> Site Suffix: J , y2 Q • Routine Q Re-inspection Q Referral Q Observation <br /> - - - - - - -- <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �5�� U �Ot,�►'Lt Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address — <br /> Inspection Date - l 7- <br /> CA w 5AO Time In Time Out <br /> Business Rep Title ' O AM % a 0 AM <br /> 367 ® PM PM <br /> Operational Status I Tire <br /> a ghat apply) Business Role � Storage Type <br /> (Fill one only) ( pp y) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ®Active Q Passenger ®Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ®OTR <br /> Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 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 ® Other C� 1 <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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> OO PRC§42956-Registration/Decal in Vehicle / [T] / <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EX7) <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred 1 CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q O (Other: § <br /> Comments <br /> Cance gee j� <br /> - J �► <br /> Inspection Form Included: Q, <br /> Comments Included: �, <br /> Im _ <br /> Bu ss Reps Signature Phone Number s Signature Phone Number <br /> -- - <br /> -- - — 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: l X � ■ <br /> ■ <br /> Pink C <br /> White Copy:CIWMB Yellow Copy:Operator E <br /> opy: <br />