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Inspection Report Number <br /> ' Waste Tire Sui „ey & Inspection Report <br /> fD7i State of California <br /> ,� COMB1817st(New Manag) Survey Form - Page 1 i s - i u 0 0 0 u <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Q Routine Q Re-inspection ® Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> Q CHP ® CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Cw w"\A i' \i r V w 4"LJ j V <br /> Physical Address <br /> Ck <br /> Inspection Date \ \ I> l d <br /> Time In Time Out <br /> Business Rep Title U 0 AM 0 AM <br /> ® PM J ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) ® Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 1 <br /> V_ A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Reg:s:ered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal -Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible En::ies Complying with Manifesting Requirements Date m <br /> 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 /> 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/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q ® 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments �1n I -� c-v 7 - <br /> S <br /> �,.u> ►�� ��,c � ��i,,��,c <br /> Inspection Form Included: <br /> Comments Included: Q �—� S <br /> Business Reps Si ture Phone Number Ins ector's Signature Phone Number <br /> • X 1 i-T---=--�- 3 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � � X R iMl P L � 1 � Z <br /> White C_,. CIWMB Yellm% Copy:Operator Pink Copy:LEA <br /> IL s <br />