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■ Waste Tire Sy & Inspection RepoOW)nspection Report Number ■ <br />Slate of California <br />A r) w7 <br />if <br />CIWMI3 181 (New 04104) f J, U <br />62 Survey Form - Page 1 <br />California Integrated Waste Management Board <br />Part A - Survev BLUE OR BLACK INK PEN <br />TPID - <br />4° <br />Comments Included, 0 <br />4�- <br />13'6441nesgRep's Signature Phone Number <br />ln�pqcto es <br />u <br />7h ' -el - r. , <br />INSTRUCTIONS ON BACK Correct: I* <br />Inspection Type (Fill one) <br />_—TT T 1 3 1 <br />.)(Ti M P <br />Site Suffix: <br />White Copy: CIWMB <br />Yellow Copy: Operator <br />Pink Copy: LEA <br /># Routine <br />0 Re -inspection <br />0 Referral 0 Observation <br />Local <br />AZ <br />If Referral, choose referral type (Fill one) <br />Identifier: <br />0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name <br />wca)/ <br />Inspected By <br />Inspector <br />ii <br />Physical Address <br />Inspection <br />Date <br />Street <br />0 AM <br />Time Out 0 AM <br />City <br />Business Rep <br />State ZIP Code <br />Title <br />t <br />0 PM <br />0 PM <br />Operational Status <br />Business Role <br />(Fill one only) <br />(Fill all that apply) <br />I(& Active <br />Generator <br />GPS Latitude <br />LE <br />L_ 0 <br />0 Closed <br />0 Hauler <br />11 <br />0 Inactive <br />Longitude`'� <br />0 Planned <br />. . . . . . . . <br />. . 0 End -Use <br />New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader <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 (3 Other <br />Part 137 --inspection of WasteTireDealer, Generator, Hauler and End -Use Facility <br />V AHAULING AND MANIFEST REQUIREMENTS <br />0 0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 0 PRC § 42956 - Registration/Decal in Vehicle <br />0 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 0 14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 0 14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 0 14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />00 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 ' <br />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 <br />0 0 Other: § <br />Comments <br />On < <br />T-1 )j)4 i- 11"fA <br />Dismantler 1( ) Tire Derived Fuel <br />ENFORCEMENTSTATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />0 Referred I CIWMB Enforcement <br />In Compliance - No Violations <br />V, I 1-f AxI, <br />nspectionform ln,cluded,-,' Ui, <br />4° <br />Comments Included, 0 <br />4�- <br />13'6441nesgRep's Signature Phone Number <br />ln�pqcto es <br />u <br />7h ' -el - r. , <br />INSTRUCTIONS ON BACK Correct: I* <br />incorrect: X <br />_—TT T 1 3 1 <br />.)(Ti M P <br />62081 <br />White Copy: CIWMB <br />Yellow Copy: Operator <br />Pink Copy: LEA <br />