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iw. Waste Tire Su_ y & Inspection Rep O Inspection Report Number <br /> rn <br /> State of California •■ <br /> California <br /> CIWMB181 <br /> Waste <br /> eManage) Survey :Form - Pagel � 1 2 - 1 Q 0 8 0. 7 6 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> } TPID- ti __TF Inspec9 h�T.ype (Fill one) <br /> Site Suffix: 7 t� ( I <br /> v Q Routine Q Re-inspection Q Referral Q Observation <br /> Local �„ -- If Referral,choose referral type(Fill one) <br /> Identifier: ":�: V� -,.f i� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility-Name r- --– –- <br /> i Inspected By Inspector <br /> Physical Address – / 12 <br /> 16 <br /> Street <br /> Inspection Date / L J_ <br /> City State Zip Code Time In Time Out <br /> Business Rep Title : F70 <br /> m O PM m ' m 0 PM <br /> < r.G I i - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) a f > (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> C� U�_o <br /> Q Active Q Passenger (D Generator @ Outdoor <br /> 1-10 <br /> Q Closed Q Altered <br /> GPS Latitude m • Q Hauler � Indoor <br /> O Q Inactive Q Truck <br /> Longitude – = d <br /> 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 /> (3 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS_ <br /> V j A i HAULING AND MANIFEST REQUIREMENTS .4 <br /> Q . PRC§42951 -Waste Tire Hauler Registration and Transport of Tires fQ. Notice Of Violation Q Extension <br /> 110Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> E C Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle o <br /> I <br /> Q I 00 114 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 /> -- --------------- . .-._ -- -- <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ® 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 Tifrse-Degibrs or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: §, <br /> Comments ___ )I t <br /> • ___�.���� f-FCc�1,�� \.Jt '+ �G� ��G*4'F ivy. lr" :� � — — t:: <br /> Inspection Form Included: Q, <br /> Comments Included: 01: J <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ) E • ,, P .� ; <br /> ■ White Copy:CfW,AB. ''ellow`Copy:Operator Pink Copy:LEA <br />