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Inspection Report Number Tire S! Y & Inspection Re or <br /> '�'• State of California <br /> CIWMB <br /> grated Waste <br /> eManage) Survey Form - Page 1 ' 3 Q 3 <br /> California Integrated Waste Management Board ..I <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> N <br /> TP <br /> ID- J Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 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 By Inspector <br /> i Physical A <br /> — —ddress---_.____.__ <br /> Street <br /> Inspection Date ! <br /> State ZIP Code Time_In Time Out <br /> Business Rep Title 0 AM O AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WhOle(PTE) ' ,, r (Fill one only) (Fill ail that app1 ) (Fill all that apply) (Fill all that apply) <br /> L, ° 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed D Altered <br /> PSLatitudeG <br /> 0 Hauler 0 Indoor <br /> IC 0 Inactive 0 Truck <br /> Longitude — ` 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill ali 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 B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS _ 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / 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 f CIWMB Enforcement <br /> 0 0 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments I <br /> r.. <br /> Inspection Form Included: 01 <br /> Comments included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X _ 62081 <br /> 'AQP. .' C,. Y L L <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />