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U Waste Tire Sui .y & Inspection Report ,e�tion Report Number S <br /> " CIWMB grated asteMana a Survey Form - Page 1 4 - 1 0 7 0 3 1 8 <br /> State of California <br /> California Integrated Waste Management Board <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 7 6 7 O ® Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: �(2n �aeh Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v Inspected By Inspector <br /> Physical Address J / — / / 3 <br /> Inspection Date <br /> AC_4_0_0r <br /> Time In Time Out <br /> Business Rep Title (f 10 AM !� ® AM <br /> O PM © / 7 O PM <br /> — — — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q End Use Q Container <br /> Q Planned Q OTR <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 /> Q Used Tire Dealer Q Auto Body ® 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 ENFORCEMENT STATUS <br /> _ - <br /> V A HAULING AND MANIFEST REQUIREMENTS 5`° ' <br /> -- - Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> m m m <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred i CIWMB Enforcement .' <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§ 18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q - anem eq ® In Compliance - No Violations <br /> Q 1 Q Other: § ' <br /> Comments <br /> Inspection Form Included: Q 1/v` <br /> Comments Included: Q �' Y�d '�7J <br /> Business Rep's Signature Phone Number Inspector's-Signature -Phone Number_i <br /> 62081 <br /> INSTRUCTIONS ON BACK t � MP L l; 3 <br /> White Copy:Cl MB Yellow Copy:Operator Pink Copy:LEA <br />