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Waste Tire Su- y & Inspection Re <br /> port 'Inspection Report Number ■ <br /> State of California <br /> CIWMB 181( Survey Form - Page 1 8 _ .1006449 <br /> New 04104) <br /> •,California Integrated Waste Management Board <br /> 3art.A TSurvey BLUE OR BLACK INK PEN <br /> f Iftness Profile Inspection Details <br /> e , 'TPID- ( Inspection Type (Fill one) <br /> t 'Site Suffix: Q Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: F 0 CHP Q CIWMB Q Complain( Q Educational Visit Q Other, <br /> Business or Facility Name Inspected By —� Inspector <br /> tr <br /> Physical Address =- �/ t (� a <br /> Vj <br /> Street <br /> s Inspection Date <br /> I` rIG.-� CIF 4 AT <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title Q AM Q AM , <br /> I QPM m m QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Ll <br /> 1 1 � `2� � (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger (D Active i' <br /> O 1 Q Closed 0 Altered <br /> GPS Latitude m • Q Hauler 46 Indoor <br /> i O Inactive 0Truck <br /> L <br /> gitudeEnd Use Container <br /> O anne <br /> OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer O Auto Repair Q Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber j <br /> I0 Service Station O Hauler O 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 /> O Notice Of Violation O Extension <br /> Q O 1 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires . <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0 PRC§42956 Registration/Decal in Vehicle <br /> O 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> O 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 /> 0 Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0: 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> - Q 'O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> (Din Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number_ <br /> It <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ', l�,!I .A'� L 1, 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />