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Inspection Report' m <br /> Nuber ■ <br /> Waste Tire Sul __%y & Inspection Report P <br /> d State of California I - 1010 $ 5 <br /> Cl=181(New 04404) Survey Form - Rage 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> TPID- _ Inspection Type (Fill one) <br /> 7 �. <br /> site Suffix: J 7 _ - -_ "® Routine Q Re-inspection Q Referral Q Observation <br /> Local / - - If Referral,choose referral type(Fill one) <br /> Identifier: �,� ;J/7,��;�.t..% t [r'rt-<_ _{ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspected By Inspector a <br /> Physical Address ,� � / ✓ / � f � I <br /> z lie <br /> ,/ _. Inspection Date : / d% 1 7 <br /> grate ZIP Code, Time In _ Time Out <br /> Business Rep Title LM : <br /> n O AM m : m o PM O O AM <br /> PM <br /> l Operational Status Business Role <br /> Tire Count(Wholet (Fill one only) (Fill all that apply) <br /> Q Active Q Generator <br /> - — I <br /> GPS Latitude O * Closed Q Hauler <br /> o Q Inactive <br /> Longitude - Q Planned Q End-Use <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 /> 0 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 <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Extension <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 0 Referred I 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 0 in Compliance - No Violations <br /> Q Q Other: § <br /> Comments �;/+.i� ,r i .` ,. '<`�::':� c •' ,•_:v.e.::.... <br /> AV <br /> szoal <br /> ■ INSTRUCTIONS ON BACK Correct:* Incorrect: X � E X AA p L E 111213 © ■ <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />