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Waste Tire Suy, & Inspection Reportspection Report Number <br /> State B California Survey Form Page 1 1 8 . 1 0 0 6 3 5 8 <br /> CIWMB 1S1(New 04/04) � ■ j <br /> California Integrated Waste Management Board -... -.- j <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> �.!ems `',�. r r ----t--- <br /> ��� � ����"� 1"'�' <br /> TPID- Inspection Type (Fill one) <br />} Site Suffix: p <br /> Routine Re-inspection Referral 0 Observation <br /> Local ."` If Referral,choose referral type(Fill one) <br /> Identifier: ,.,, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical`Address <br /> Street <br /> Inspection Date <br /> I Time In Time Out AM <br /> Clty State ZIP Code _ _-- — _-,- __-, ) <br /> Business Rep Title 0 AM <br /> O PM _ 1 �- g Q PM <br /> Operational Status rtre Type Business Role Storage Type <br /> �] (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (a Active 0 Passenger 0 Generator 0 Outdoor <br /> �+ Latitude i <br /> 0 0 Closed 0 Altered <br /> GPS 0 Hauler 0 Indoor <br /> _ O 0 Inactive 0 Truck <br /> Longitude – Lii I - I <br /> 0 Planned 0 OTR 0 End-Use 0 Container <br /> _ x _ <br /> ti . <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Refreader 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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registraion/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 (a)(ti)(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 or EXT) <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 1 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 I Other: §,---- ----- <br /> Co`mm'ents/ <br /> -- <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X A M IT' I- E,— <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />