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Waste Tire S&ey & Inspection RepoloInspection Report Number <br /> State of California <br /> CIWMB 181tManageSurvey Form - Page 1e ) <br /> California Integrated Waste Management Board <br /> Part A- Su rve BLUE OR BLACK INK PEN <br /> T <br /> spectiott 066at� � F <br /> TPID- ' l Inspection Type (Fill one) <br /> Site Suffix: Z C) @ Routine Q Re-inspection Q Referral Q Observation <br /> Local - - - If Referral,choose referral type(Fill one) <br /> Identifier: )a .fir CX,: J U\i t c UL1 ni Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - - - <br /> Inspected By Inspector <br /> Physical Address -�� Lj LO] ! <br /> Street ` <br /> ►.. L9 � Inspection Date <br /> City <br /> City � Sian ZIP Code Time Out <br /> Time In <br /> iTi ...._-_-._ __. . -- _-- <br /> Business Rep Title )I O AMO AM <br /> OPM : F <br /> 0 PM <br /> v 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 /> Active Q Passenger I'I (�q Generator Q Outdoor <br /> D Q Closed Q Altered I <br /> GPS Latitude ' Q Hauler Q Indoor <br /> L� I—L-L—LL <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 (5 Other s <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> HAULING/AND MANIFEST REQUIREMENTS <br /> Q Q Notice Of Violation Q Extension <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 m / Fn / Ell <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive 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 In Compliance - No Violations <br /> Q Q Other: § - I <br /> Comments i <br /> r1�kG�-6 <br /> ,Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature .Phone Number l9sirpector's Signature Phone Number <br /> - - - -- <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X XIA M PI '•/ 112131 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />