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i <br /> Waste Tire SVe & Inspection Re opospection Report Number <br /> State of California 11 114 3677 <br /> CIWMB181 <br /> Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey __- ____ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` I e Routine Q Re-inspection Q Referral Q Observation <br /> Local lIf Referral,choose referral type(Fill one) <br /> Identifier: `=�M� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> VVtv+ Cowl vi S 9 <br /> Physical Address � yj2 <br /> \ Inspection Date ,+ <br /> L.oG (� q5�t t L <br /> Time In Time Out <br /> Business Rep Title � � � 0 AM "'� Q AM <br /> ,.� b,� le_ �� � ® PM � � ! 0 PM <br /> - - -- --- - -- -- - -- - — Operational Status Tire Type Business Role Storage Type <br /> L (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ®Active ® Passenger ® Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude — i ® OTR Q End-Use ® Container <br /> Q Planned <br /> Business Type (Fill all that apply) <br /> j 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 Other f,Z L) <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> Vi A HAULING AND MANIFEST REQUIREMENTS <br /> Q1 Q Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. i Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle I <br /> Q 10 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers j Q Referred/CIWMB Enforcement <br /> Q O 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 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> _ems <br /> ,Inspection Form Included: QI <br /> Comments Included: ® -- `� J `�1-�F �- <br /> Bu loess Rep's Signature one Number I ct gnature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />