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Inspection Re <br /> Waste Tire Sulky & Inspection Report p port Number <br /> _ _ <br /> 'c State of California �}�i ��j <br /> California Integrated WaseeManagementBoard Survey Form - Page 1 L 1 _ 1 0 0 6 4 9 7 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> k�. <br /> TPID- ! �` Inspection Type (Fill one) <br /> Site Suffix: � `' t �_� � ', �--� <br /> 1 <br /> ' 0 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 Inspected B <br /> _ p y Inspector <br /> iJ <br /> Physical Address <br /> Street <br /> F Inspection Date <br /> City State Zlp Code Time InTime Out <br /> FT <br /> Business Rep Title © AM 0 AM <br /> . O PM = : F <br /> � OPM <br /> ..j <br /> AK <br /> Operational Status Tire i, W Business Role Stora 1pe" <br /> 1 <br /> ire COtlnt�Whole�PTE) � ;j(Fill one only) (Fill.a(�"�UANA �� � (Fill all that apply) (Fdl allP���t�l �I;y��" <br /> 0 Active 0 FA�` 0 Generator 0 Od,jp `v <br /> 4104 <br /> Latitude D 0 Closed D Ar " " W <br /> GPS �L . 1r1,, r 0 Hauler 0 In t 2,Rq �R <br /> D 0 inactive D Tru,c o <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <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 /> VI 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 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 LTI <br /> m / m <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/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 <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: x l <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />