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Waste Tire Suy & Inspection Resulor - nspection Report Number <br /> • .ari: State of California J 1— Rep -... _.._.._. ._ ■ <br /> CWMB grated Waste <br /> eManag) Survey Form - Page 1 ' 0 10 <br /> California Integrated Waste Management Board _ <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details I, <br /> TPID- �� �� _ (, Inspection Type (Fill one) <br /> Site Suff ` } / <br /> Q Routine Q Re inspection Q Referral 00 <br /> ix: <br /> bservation <br /> Local i If Referral,choose referral type(Fill one) <br /> Identifier: <br /> '-.((!` Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> p Y Inspector <br /> Physical Address <br /> r' <br /> Street <br /> Inspection Date <br /> City - State Zip Code TimeLL In Time Out <br /> Rep Title Business Re 0 AM <br /> PM <br /> e � QPM� <br /> t >�tiG7 'r <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 /> I�e� <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude • ��Q� <br /> Q Hauler Q Iridool <br /> O <br /> !; Inactive Q Truck <br /> Longitude - Q Planned QOTR Q End Use Q Container <br /> IEtl,�rl ;1 a .r' -' ,atl Yr far/✓ <br /> ..�:. .r,-,. �NM ys,. <br /> Q New Tire Dealer Q Auto Repair Q Trucking 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 (E) 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 /> ----- ---- 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 Date EDEIXII <br /> Q 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 /> Q 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/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 Q In Compliance - No Violations <br /> Q Q Other: § --- <br /> Comments / <br /> t, <br /> Inspection Form Included: OI <br /> Comments Included: Q' _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X tv ", A A, �8 L � 1 a <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />