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Waste Tire Sway & Inspection Report, Ins_pction Re ort�_p 0 <br /> Number <br /> ®a A State B California /y <br /> CIWMB 181(New Manag ) SurveyForm - Pape 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business ProfileInspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: L / ' _� - �> <br /> �r (� ✓ 0 Routine 0 Re-inspection 0 Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: F�_7v ,,�. -}, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit o Other <br /> Business or Facility Name <br /> �^ Inspected By Inspector <br /> !- 1 <br /> Physical Address <br /> Street <br /> Inspection Date <br /> Citv ` Time In _ Time Out <br /> State Z/P Code: <br /> Rep Title O AM O AM <br /> Business Re <br /> L.._ 0 PM d QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that ap", (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) r <� <br /> Active 0 Passeng 0 Generator 0 Outdoor <br /> _TTT] <br /> Latitude - 0 0 Closed 0 Altered <br /> GPS Q Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude Container <br /> - 0 End-Use Planned 0 OTR 0 0 <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 Derivecl Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer .,o Colleclon_ Q Crumb Rubber <br /> 0 Service Station @ Hauler 0 Agriculture o Shredder o Other I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 — Q Notice Of Violation 0 Extension <br /> 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/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 /> _J <br /> Commentt p % <br /> � - <br /> 1� J1_ <br /> Inspection Form Included: 0 <br /> Comments Included: �' <br /> Business Rep's Signature Phone Number inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:9 Incorrect: X Y *'' p ;(� I 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pjnk Copy:LEA <br />