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Waste Tire Sdty & Inspection Repo Inspection Report Number <br /> State ofCalifornia - :n _-- =•°■ <br /> Survey Form - Page1 - 1 006466 <br /> CIWMB 181)(New 04/04) <br /> California Integrated Waste Management Board _-_- __ _ -- _ <br /> Part Ac <br /> SurveyBLUE OR BLACK INK PEN <br /> Inspection Details'" <br /> TPID- - Inspection Type (Fill one) <br /> Site Suffix: <br /> Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> Physical Address <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Bu0 AM 0 AMsiness Rep Title [T <br /> 0 PM ` Q ' L Q PM <br /> __T <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all fiat apply),,, <br /> �rNP Q Active Q Passenger Q Generator Q Outdoor <br /> GPS <br /> Latitude . 0 Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> r— _ <br /> LJ___— D Q Inactive Q T p <br /> m <br /> Longitude - Q Planned 0 ', �t Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> QNew Tire Dealer QAuto R <br /> e air Q Trucking a Fleet^{ .,.,..Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 <br /> V I 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 Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date1:11 / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submiltal-of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years - 1 -- <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 r <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> rta, . t • <w fell tk t <br /> O Oh� <br /> Other: § ( ; <br /> Comments t <br /> Inspection Form Included: Q <br /> Comments Included: - <br /> Q Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X Lim u A 1r0,,P � � �? 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />