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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB 1st(Now Maage Survey Form - Page 1 1 4 - 1 0 1 4 7 3 7 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: *Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: --��'�' <br /> J t>^ �- !OCHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name h Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> r 0 / ' C) f <br /> Time In s Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM O PM <br /> Operational Status Tire Type Business Role I Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) I (Fill all that apply) <br /> O Active Q Passenger • Generator I O Outdoor <br /> 0 <br /> 0 Closed Q Altered <br /> GPS Latitude 0Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> S 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility i ENFORCEMENT.STATUS , <br /> PRC HAULING <br /> -Waste Tire Hauler Re l/ <br /> V A HAULING ANI).MANIi=EST REQUIREMENTS <br /> Q Notice Of Violation <br /> O Q § Registration and Transport of Tires f! <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> Q ! Q I § 9 Compliance Geadlir~e <br /> O O PRC§429.56-Registration/Decal in Vehicle r <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date I I <br /> 0 O 14 CCR§ 18459-1 (a)(b)(c)-Tire Program ID Number from CIWMB m m <br /> s. <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (RegtltredfQrNQV <br /> I ' <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years t f <br /> IO O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q RSf C+ f C 1+IIAt Rt Pa <br /> ✓/�� %' <br /> O O 14 CCR§18461 - Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O � O <br /> I <br /> Other: § 1 ,} " _'y �/'w//• <br /> Comments /� irk /.4 <br /> Inspection Form Included: Q � <br /> Comments Included: 0 ---- — - - - - <br /> Business Rep's Signature Phone Number I s at a Phone Number <br /> INSTRUCTIONS ON BACK CorrIii �_ Incorrect (� CJI <br /> A N, P � EY a3 62081 <br /> While Copy:CIWMB Yellow Copy,Operator Pink Copy:LEA <br />