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® L Waste. Tire--Suy & Inspection <br />B@Fij".pr State of California <br />CIWMB 04/04) <br />r. California Int grat d,81 Was eeManagement Board - survey Form - Pag <br />{,,Part A - Survey <br />eport speption Report Number x■ <br />1 4-1014.844 1 <br />BLUE OR BLACK INK PEN <br />Business'Owl a Inspection Details <br />TPID - : Inspection Type (Fill one) <br />Site Suffix: \ �` �• \ _ �_ (g) Routine. Q Re -inspection Q Referral Q Observation <br />Local If Referral, choose referral type (.Fill one) <br />Identifier: , Q Educational Visit Q Other <br />Business or Facility Name - � �� <br />Inspected By Inspector <br />Physical Address , — , , 4Z a , r c t <br />Street <br />M � Inspection Date <br />City State ZIP Code Time In Time Out <br />Business Rep Title OAM ® AM <br />s23, k <br />QPM [ail `. QPM <br />Operational Status Tire Type Business Role Storage Type <br />Whole/PTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />Tire Count <br />( > ❑' f ` J (R) Active CE) Passenger, @, Generator Outdoor <br />0 Q Closed Q Altered <br />Caps Latitude m • � Q Hauler Q Indoor <br />O Q Inactive Q Truck <br />Longitude — : Q Planned Q OTR Q End -Use Q. Container <br />Business Type (Fill all that apply) <br />® 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 />Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use,Facility <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m/m/m <br />(Required for NOV or EXT) <br />V P.: <br />Q Referred / CIWMB Enforcement <br />ff <br />Comments <br />L <br />A, <br />� �,y,:•�;i• `�`. ,�� �:b�ta X.t <br />i 4c <br />nspection Form Included: 0 <br />Comments Included: Qi -- <br />Business Rep's Signature Phone Number inspector's Signature Phone Number <br />U I I, . <br />INSTRUCTIONS ON BACK Correct:* Incorrect: ) � E� A MP L E 1 12 13 62081 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Copy: L_EA ® S <br />V <br />! A , HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951-- Waste Tire Hauler Registration and Transport of Tires <br />Q <br />. Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 -:-Responsible Entities Complying with Manifesting Requirements <br />Q • <br />Q <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />Q_ <br />Q <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />�. <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />I <br />Q <br />Q <br />14 CCR § 18462 - Manifesf�SystetYr-R'eq ilrements for Tire Dealers or Waste Tire Generators <br />Z <br />Q <br />Q <br />Other: § <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m/m/m <br />(Required for NOV or EXT) <br />V P.: <br />Q Referred / CIWMB Enforcement <br />ff <br />Comments <br />L <br />A, <br />� �,y,:•�;i• `�`. ,�� �:b�ta X.t <br />i 4c <br />nspection Form Included: 0 <br />Comments Included: Qi -- <br />Business Rep's Signature Phone Number inspector's Signature Phone Number <br />U I I, . <br />INSTRUCTIONS ON BACK Correct:* Incorrect: ) � E� A MP L E 1 12 13 62081 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Copy: L_EA ® S <br />