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=:e Inspection Report Number <br /> Waste Tire Su&y & Inspection Repor <br /> State of California <br /> � a CIWMB181(New 04104) Survey Form - Page 1 - 10 10 0 8 5 <br /> California Integrated Waste Management Board <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> , Inspection Details <br /> TPID- Inspection le, <br /> [Oil <br /> Inspection Type (Fill one) <br /> Site Suffix: ) b —r/ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: '�'j yt„ �� �� 0 u(r( I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> (10 <br /> Physical AddressI I I I U ��;G1 y • l t%(% <br /> I '7I L-00`vi.� — <br /> Street 'D-DIC � Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep 1 Title ( y1I AM 0 AM <br /> - D PM I ' I I I 0 PM <br /> Operational Status ire Type Business Role L(Ffllra <br /> Typ <br /> Tire Count (Whole/P rE) I I (Fill one only) ,Fill all that apply)' (Fill all that apply) hat ap" <br /> Q Active Passenger Q Generator door <br /> Latitude <br /> U ® Closed Q Altered <br /> GPS Q Hauler or <br /> Q Inactive Q Truck <br /> Longitude - I v Q PlannedQ OT Q End-Use <br /> Business 1 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 /> t ` <br /> Q Service Station Q Hauler Q Agriculture Q Shredder a Other Ill. <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT S'lATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - - - 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 /> O Q Other: <br /> Comments �� (3i-t f t►�.{ �r' 1 g-�( l �Ci i) ��'f.l. �, 4a r `�1�� I�} rl�C to( �{.� WO KI Ci y <br /> Li <br /> �4 i ��✓( � <br /> I i ct l I th1 cr'�. r�.ti f�� ' ����,-"� t; r v �jn�Ct.�( O 1' r 0110.(.f . <br /> — _11111mr- —low- <br /> - <br /> Inspection Form Included: O <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number Inspector's <br /> Ins(pector's Signature Phone Numb] <br /> X `r I I I l I11213162081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � X A �h P � � <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />