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Ins <br /> ® Waste Tire Sy & Inspection Repor pection Report Number <br /> ��� State of California <br /> CIWMB 181 teManage) Survey Form - Page 1B KSI <br /> California Integrated Waste Management Board , <br /> Part A- SurveyPEN <br /> Business Profiley� <br /> In�?' .;_ � <br /> Inspection Type (Fill one <br /> } Site Suff <br /> TPID- ix: ( I ,_ ' I I ( .'a I ,. ) I Routine Q Re-inspection 0 Referral 0 Observation <br /> Local -- — If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected B <br /> p y _ Inspector <br /> I I � t <br /> Physical Address EL <br /> i IJ <br /> Street <br /> Inspection DatebE- <br /> r• .:� <br /> City State ZIP Code-� Time In Time Out <br /> Business Re �.. <br /> p Title0 AM <br /> O AM <br /> 0 PM O PM <br /> Operational Status Ti4%pe 3WBusiness Role Storage Type <br /> The COUnt(WhoIeIPTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> _ Latitude <br /> 0 0 Closed 0 Altered <br /> 0 Hauler 0 Indoor <br /> GPS <br /> 0 0 Inactive 0 Truck <br /> Rude – <br /> g 7_7 0 Planned 0 OTR O End-Use 0 Container <br /> Lon <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part <br /> Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. 'd <br /> Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 1 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 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 0 Referred I CIWMB Enforcement <br /> 0 0 1 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 'Other: §0 0 In Compliance - No Violations <br /> Comments <br /> Inspection Form Included: Q' <br /> Comments Included: O, -- _ <br /> Business Rep's Signature Phone Number inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � _o, Ojo p� <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> i <br />