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Ins ection Re ort Number <br /> � Waste Tire Su 'y & Inspection Report ��- _p _ p � <br /> State of California 1 � � <br /> , CIWMB181 <br /> asteMana a Survey Form Page 1 1 0 1 t <br /> California Integrated Waste Management Board - -- <br /> Part A- Surve I BLU_E OR BLACK INK PEN <br /> Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: r 171 .'% i n Q)Routine Q Re-inspection Q Referral Q Observation <br /> Local - If Referral,choose referral type(Fill one) <br /> Identifier: �� '_'CA. f LA ; _, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street Inspection Date EEI �-- <br /> __.__ Time In 4 e'Out <br /> City State ZIP Code Business Rep Title 0_AM0 AM <br /> EL_ <br /> _J� 0 P � � QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> �l (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) .a, <br /> ,d r <br /> Active Q,Passenger (D Generator Q Outdoor <br /> O Q Closed Q Altered ! <br /> GPS Latitude ; ( Q Hauler 0Indoor <br /> Q Inactive T'tQr"Truck <br /> 10 ;r} " <br /> Longitude — Q Planned r'Q Q End-Use Q Container <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 Q 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 <br /> — ---- Q Notice Of Violation Q Extension <br /> O 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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <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 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 I CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> 0 0 Other: <br /> Comments + <br /> Inspection Form included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature.__­ Phone Number <br /> A 62081 -ti <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy LLA <br />