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,. Waste Tire Survey & Inspection Report InspectionRiANSAW <br /> State of Callfomla <br /> C <br /> IW <br /> M <br /> B <br /> ifJ1(New 041W) Survey Form - Page 1 5-- 1 01 3 2 3 6 <br /> Callfomla Inteyratetl Waste Manepoment Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID_ Inspection Type(Fill one) <br /> Site Suffix: (� �J 6 - ®Routine 0 Re-inspection O Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: - o M �,��� Q CHP Q CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name --` <br /> Inspected By Inspector <br /> Ph ical Address <br /> jStreet <br /> Inspection Date ' (� <br /> �7ity � tate�Z`ode <br /> �J Time In Time Out <br /> rty <br /> Business Rep /✓Title Q AM 0 AM <br /> m <br /> L—�—J m 0 PM m' 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> 11 I I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) e i I t sj�'�p <br /> Active ®Passenger ®Generator ®Outdoor <br /> Latitude j I I 0 O Closed 0 Altered <br /> GPSJ ®Hauler ®Indoor <br /> O Inactive O Truck <br /> ( <br /> Longitude 0 End-Use 0 Container <br /> I I I O Planned Q OTR <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer 0 Auto Repair 0 Trucking Fleet O Government 0 Retreader O Dismantler O Tire Derived Fuel <br /> ®Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> O Service Station 0 Hauler O Agriculture Q Shredder 0 Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A j HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle f <br /> O O 14 CCR§16459 -Responsible Entities Complying with Manifesting Requirements Date W m /m <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or DC7) <br /> 0 Q 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 i CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q 10 1 Other: § -— — <br /> Comments �1�G—/,�c� -- �iTLs -c v,� W�-G--T_��•-e. �X r_5•11.�L�_( -• t �%� <br /> 4 jn_l 15 —7- <br /> IC <br /> �or- (�E�f 1,�.�"I'� D"C— ��—TI'j'� /C%t� WGtS..rG+1C._ "1 1>•'�S Q-��,+ <br /> -c_ c>, Z.'7,1- 07 <br /> Inspection Form Included:0 �^14 t _ •�•-•-^wCl <br /> Comments Included:®— / �� — - -— - <br /> Business Rep's Signature Phone Number s Signe r Phone Number <br /> INSTRUCTIONS ON BACK Correct:* incorrect:�ip 9 E X M P L E _1112131 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operalor Pink Copy:LEA ® ■ <br />