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== Waste Tire Su. „ay & Inspection Report, Inspection Report NumberState of <br /> ■ <br /> CIWMB181'(New 04/04) SurveyForm - Page 1 I 1 - 1143979 <br /> California Integrated Waste Management Board <br /> -t A-Survey BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> r rID- Inspection Type (Fill one) <br /> Site Suffix: ' 02 _I ' 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local /'� If Referral,choose referral type(Fill one) <br /> Identifier: 5`A � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name // Inspected By Inspector <br /> Physical �d�ess a J <br /> Inspection Date 1 0 <br /> �tC.�t7rY� �t5�a5 l <br /> Time In Time Out <br /> Business Rep Title ] Z /^� O AM C� O AM <br /> CJ O � PM c [ QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Q Active Q Passenger Generator Q Outdoor <br /> GPS Latitude O 0 Closed 0 Altered Alllo - <br /> O Q Inactive •Truck Q Hauler 0 Indoor <br /> Longitude – 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V � A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> QPRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 O - - — <br /> 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § — <br /> Comments <br /> - - -- –-- <br /> i <br /> I._-..pection Form Included: 0 <br /> Comments Included: 0 "S �Ie <br /> Business Rep's SignalPhone Numbers – s t ignature _ Phone Number <br /> INSTRUCTIONS ON BACK [Correct-* Incorrect: X (AP1 V! + 141 P 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />