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ay y Waste Tire Su0&y & Inspection Report�lnspection Report Number ■ <br /> State of California <br /> CIWMB 181( e <br /> California Integrated WasttManage Survey Form - Pae 1e Management Board J g <br /> Part A- Surve _ BLUE OR BLACK INK PEN <br /> TPID- " Inspection Type (Fill one) <br /> Site Suffix: Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local vT If Referral,choose referral type(Fill one) <br /> Identifier: <br /> •;;- A 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> Physical Address / r <br /> Street T j� <br /> Inspection Date <br /> City ��-�� State ZIP Code Time In Time Out <br /> Business Rep Title Ell 0L1.-J 0 PM — Fj] <br /> O PM <br /> 1 <br /> ,t AM <br /> Operational Status Tf"r" r Business Rolevtorage Type <br /> .� (Fill one only) (F)I a �tnat" p1a (Fill all that apply) (Ftll dlihstppJy); <br /> 0 Active Pa5seligeC' 0 Generator (� CJutdotir. <br /> Latitude �.�NINE[:= O 0 Closed Di gltercd' <br /> GPS EII Ei_I- <br /> @� Q Hauler IndO Inactive a"0 Truck k <br /> Longitude - 1 C?TR End Use elher <br /> g { 0 Planned (� <br /> i r . <br /> Business Type '(Fill dll tj <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 <br /> Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - <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-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / 1:11 / IE <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 (Required for NOV or EXT)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 /> 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 Gen~'�rators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> I t2ir <br /> Inspection Form Included 0, <br /> Comments Included QI - , -- - 4 .µ <br /> f3usmess Rep"s Signature Phone Number inspector's tgnatur� Phone Nurnbew. <br /> INSTRUCTIONS ON BACK CorrectV Incorrect: M� ' �_ 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />