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■ Waste Tire Sey & Inspection Repor __Inspection Report Number <br /> . Wad State of California ___.. ..-.. ............._ ■ <br /> Cgrated asteManage Survey Form - Page 1 ! 7 - 1 0 0 0 4 5 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> �I� �t«" <br /> ,��rLt✓' �^x, <br /> r.� <br /> TPID- w Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalT If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> r <br /> Physical Address <br /> Street <br /> j Inspection Date <br /> City State ZIP Code`) Time In Time Out 0 AM <br /> Business Rep Title O0 AM <br /> PM ' 0 PM <br /> „^.• Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that appb Fill all that app Y) (Fill all that apply)Count(Whale/PTE) . <br /> r G5M 0 Active D,Passenger~ l 0 Generator 0 Outdoor <br /> D 0 Closed 0 Altered <br /> GPS Latitude - 0 Hauler 0 Indoor <br /> D 0 Inactive 0 Truck <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <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 Derived Fuel <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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility 1ENFORCEMENTSTATUS <br /> VA. HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice Of Violation, 0 Extension <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 /> mm / 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 orEXT) <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 O In Compliance No violations <br /> 0 0 Other: <br /> Comments ) ; <br /> INSTRUCTIONS ON BACK Correct: Incorrect-�X <br /> . x(/ i 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />