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�y & Inspection Report*_Ins ection Report Number <br /> Waste Tire Sup p <br /> State of California <br /> CIWMB181 <br /> Waste <br /> eManag) Survey Form - Page 1 5 0 0 6 16 8 <br /> California Integrated Waste Management Board ..__.__ -...... .... ....... .. _-.- 1. I <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> (�{ y� y Jri�'yx'"`�' 1 ��" k �F f' 1iM 3 ! FC ✓ d ;1 }dl C" M,� !' 1 b <br /> PCS )a,�� r�r)g"yl 5 r, y" r ' r <br /> �h..�,. ,.J,.. r.a�..._J-..,.,�..:,�.,w%");r� �. r_r rrvu'n 1__5..1. �.�._, .� .�...'rc .....W <br />} TFTE <br /> PID- _ Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral i>. Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: `.I : ' �•t t I'+�r•. ! 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name -- - <br /> Inspector <br /> Inspectedy spe <br /> I Physical Address <br /> Street <br /> Inspection Date <br /> a <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title. a 0Loa <br /> 0 AM Q AM <br /> ( P PM <br /> 1, <br /> r i M � O <br /> I Operational Status Tire Type r, Business Role Storage Type <br /> (Fill one only) (Fill all that epply) (Fill all that apply) (Fill all that apply) <br /> 10 <br /> ®111111,11 110i 11,1E <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude O 0 Closed 0 Altered <br /> GPS 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Tluck � <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer Auto Body Car Dealer Collection 0 Crumb Rubber <br /> O O O O <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 . I HAULING AND MANIFEST REQUIREMENTS 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 /> M / M / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <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 I 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 /> I5 t L'iflt' o 5--r<"s.r!-': Ii J <br /> f;I•'t '+li..`F{{'r�� <br /> /Jt� <br /> Inspection Form Included: 0' <br /> Comments Included: 0 - - p, g _ pSignature,. <br /> Business Re s Si nature Phone Number Ins actor's Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br /> i <br />