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Waste Tire Spey & Inspection Reporo- Inspection Report Number <br /> State of California J n b <br /> CIWMB1811 Waste <br /> Survey Form - Page 1 �_.__� 4 - 0 1 3 0 1 � <br /> California Integrated Waste Management Board - -- �' <br /> Part A Survey BLUE OR BLACK INK PEN <br /> Profile Inspection Details <br /> _.•_,.W <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Q Routine (2) Re-inspection Q Referral Q Observation <br /> Local ice, If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility`Name { ( Inspected By Inspector <br /> , <br /> Physical ;Address l ( 1 L 1'2_ <br /> Street �l r / ` Inspection Date <br /> Crfi - ~ State ZIPCode Time Code Time Out _ <br /> Business Rep Title <br /> EJ__In <br /> 1 ; O0 AM 0 AM <br /> PM . �^ O PM <br /> Operational Status Tire Typer Business Role Storage Type <br /> (Fill one only) (Fill all that apply)` (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger Q Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> Latitude Q Hauler Q Indoor <br /> GPS <br /> O. Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> . - <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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station I& Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 m m / FT] <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 1 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § __ — <br /> Comments <br /> t c,i rr (��> f G. _Ct ��. � �'� k; �nl lT S h 7 � .I S u <br /> I•, - <br /> e � L� _ <br /> S dale,)-- 7 (e-� � 1 S 11101 'S7 5 `"1 <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X t� A 14 <br /> White <br /> � <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />