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• <br /> Waste Tire '15 <br /> WAY & Inspection Report nspection Report Number <br /> State of CaliforniaCIWMI3 04104) <br /> ii _. <br /> California Integrated f W81 as eeManagement Board Survey Form - Pagel i_ 5 - t, 1 0 14 + i LI <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> r,c <br /> rr <br /> r„�.�' <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: -' ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local _ 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 /> Ph s cal Address <br /> Inspection Date <br /> Street <br /> --- p <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title m 0� AM 1 1 0 AM L�... 0 P PM <br /> Operational Status Tire Type Business Role Sforage Type <br /> (Fill one only) (Fill all that app (Fill all that apply) (Fill all that apply)' <br /> 0 Active 0 Passenger'” 0 Generator 0 Outdoor <br /> O ® Closed Altered <br /> GPS Latitude I 0 Hauler 0 indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - <br /> g� 0 Planned D OTR 0 End-Use 0 Container <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 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-Registration/Decal in Vehicle <br /> 0 0 li 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 I 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 0 Other: § <br /> Comments J - - <br /> _, - <br /> Inspection Form Included: 0' <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X �/ y ,B', ' 13 62081 <br /> vo ® ■ <br /> z.M ,; White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />