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Waste Tire Sury & Inspection Report p p " <br /> T[iG <br /> section Re ori Nfimber ■ <br /> e CIWMB 81st State of Manage Survey Form - Page 1 1 7 � 1 Q 1 .3 31 2 . <br /> arc:a <br /> California Integrated Waste Management Board ' <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- mInspection Type (Fill one) <br /> Site Suffix: 1+ y Q 1 Q Routine ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �,r �- <br /> L J , Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Car. r ' I`-ir.�". J�r_.e— I p . <br /> Ph sical Address <br /> Street / <br /> Inspection Date <br /> City State ZIP Code Time In Time Out. <br /> Business Rep Title <br /> r ` EE 0P EEI 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ❑ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ActivePassen er <br /> � <br /> Q g ®Generator Outdoor <br /> O Q Closed 0 Altered <br /> GPS Latitude m . Q Hauler Q Indoor <br /> 0 Q Inactive Q:Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill 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 /> Used Tire Dealer. Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> LQ 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 /> 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 <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 In Compliance - No Violations <br /> Q 1.Q 1 Other: § <br /> Comments t '///j, ) , <br /> Lj- <br /> Inspection Form Included Q. <br /> 71 <br /> Comments Included Q �_.._ ....-.1- t _.. _.. <br /> J Business Rep's Signature Phone Number Inspector s,Signatu a Phone Number <br /> i <br />{ INSTRUCTIONS ON BACK Correct:9 Incorrect: )( , ,, V P .� 62081 L <br /> P ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® S <br />