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Waste Tire Su & Ins ection Re Or Inspection Report Number <br /> Nia <br /> Y p p State of California <br /> _. <br /> CIWMB181 <br /> Waste <br /> eManage) Survey Form - Page 1 11 9 - Q 1 3 6 9 j <br /> California Integrated Waste Management Board <br /> Part A Surve BLUE OR BLACK INK PEN <br /> Bustn", , <br /> Inspection Details <br /> ELTPID- Ins ection T <br /> Site Suffix: L - <br /> p Ype (Fill one) <br /> DE <br /> �� ® Routine 0 Re-inspection Referral Observation <br /> — o <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: .;, <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - - -- - -- - <br /> Inspected By Inspector <br /> Physical Address - f <br /> 1 <br /> I Street <br /> Inspection Date �1--^� <br /> Crty State ZIP Code I Time In _ Time Out <br /> - - : [- <br /> Business Rep Title ® AM <br /> Q AM <br /> y O PM QPM <br /> � � <br /> Operational Status Tire Type Business Role Storage Type <br /> r(Fill one only) (Fill all that apply): (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude . [ ---]- o 0 Closed 0 Altered <br /> 0 Hauler (� Indoor <br /> s. <br /> 0 Inactive 0 Truck <br /> Longitude - FT7 - [ � 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (r=ill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Q 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 FacilityENFORCEMENT STATUS IRK <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. <br /> 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 /> 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 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 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 I 0 Other: § <br /> Comments <br /> Inspection f=orm Included: 0' - - <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> L ( ; 1 L 62081 <br /> INSTRUCTIONS ON BACK Correct:16 Incorrect: X .0 <br /> ■ __— - 3 <br /> © ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />