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072000 50007 <br /> ■ =' ,- Waste Tire Survey & Inspection Report . Inspection Report Number ■ <br /> stator Calirwnla Survey Form Page 1 1 3 - 1 Q 31 Q <br /> CnnrB 101(Naw"a"i y 9 <br /> CNHomla Intayratad Waau Manapament Board <br /> Part A-Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile 7 Inspection Details <br /> TPID- I Y Inspection Type (Fill one) <br /> Site Suffix: l / 0 Q✓� �jj / O Routine ®Re-Inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: c ` 1�4q c f�-- ✓/,, O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name '`% <br /> � In�pect�d By Inspector <br /> Physical Addres� � � �'� <br /> Srredt o 6 Z a� <br /> Inspection Date <br /> Gt� y lata ZIP ode Time In Time Out <br /> Business Rep / J Title m m O AM O AM <br /> O PM m m 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 /> Active ®Passenger ®Generator ®Outdoor <br /> O O Closed O Altered <br /> Latitude <br /> GPS O Hauler O Indoor <br /> O O Inactive Truck <br /> Longitude – O Planned ®OTR ®End-Use ®Container <br /> Business Type (Fill all that apply) _ <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder ®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 Q Extension <br /> O O <br /> PRC§42951•Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Regis trationlDecal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / Ffl <br /> / [I] <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required/or NOV or EXTJ <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days O o - - -. _ <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred!CIWMB Enforcement <br /> O I O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators� O ®in Compliance - Na Violations <br /> O O Other: §,— <br /> Comments <br /> 6:z <br /> Inspection Form Included:O <br /> Comments included: t(�p <br /> Business Rep's Signature Phone Number pe ter'.Sign re Phone Number <br /> �-�( 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:tX(� e I x a M P L E 1 2 3 ® ■ <br /> ■ White Copy CIWMB Yellow Copy Operator Pink Copy:LEA <br />