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Inspection Report Number <br /> Waste Tire Su y & Inspection Report* <br /> State of California <br /> CWMB grated Waste <br /> eManage) Survey Form - Page 1 _ 1 - 114116 6 <br /> California Integrated Waste Management Board _.... <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile ' Inspection Details <br /> TPID- L L - Inspection Type (Fill one) <br /> Site Sufifiix 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �L� l ID CHPaI,choose <br /> CIWMBrral type(Fill ) <br /> 0 Complaint 0 Educational Visit 0 Other <br /> `L <br /> Identifier: <br /> Business or Facility Name r Inspected B <br /> p Y Inspector <br /> "�- <br /> Physical Address C <br /> E <br /> #=era= p <br /> Ins ection Date <br /> State ZIP ,)dp Time InTime Out <br /> ..... .... . .. <br /> O AM Q AM <br /> Business Rep Title <br /> I IC <br /> ' Q PM �� ? QPM <br /> ACX1 ✓, <br /> Operational Status Tire Type ype Business Role Storage Type <br /> ' 77777— 1 i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill at that apply)', <br /> Tire Count (Whole/[ TES <br /> (ja Active 0 Passenger 0 Generator 0 Outd(;)g <br /> r <br /> iO 0 Closed 0 Altered <br /> GPS Latitude �_ 0 Hauler 0 Indoor <br /> _...-', i - 0 Inactive 0 Truck <br /> Lon itude - 0 End-Use 0 Container <br /> Longi •; ) 0 Planned 0 OTR <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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> _ <br /> ... - .... __—. ._. 0 Notice Of Violation 0 Extension <br /> 0 1 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 M / Fp / [Il <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive 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 <br /> 0 In Compliance - Na Violations i <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form lncluded: 0 <br /> Comments Included: 0 <br /> Business,Rep's Signature Phone Number Inspectors Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X JE X:A Fid I_ F e <br /> ® White Copy:CIWMB Yellow Copy:Operator ��Pink Copy:LEA <br />