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Waste Tire SAW & Inspection Reporil nspection Report Number <br /> State of California - <br /> CIWMB181 <br /> asteManag( Survey Form - Page 1 9 <br /> California Integrated Waste Management Board <br /> Part A Survey BLUE OR BLACK INK PEN <br /> usfness t j,Insp�ckom F1eta•'f!s <br /> TPID- Inspection Type (Fill one) <br /> Site Staffix: i ! ( tJ +/ 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> ----Local <br /> If Referral,choose referral type(Fill one) <br /> Identifier: '�;# CjC{ k i 1,(f 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected B <br /> 7 P s Y Inspector <br /> Physical Address t I l J <br /> Street <br /> Inspection Date <br /> City w State ZIP Code I Time In _ T_ime Out <br /> Business Rep Title O AM O AM <br /> r <br /> ET_ <br /> ..�,� � [�O PM `. O PM <br /> Operational Status Ttre Type. ' Business Role Storage Type <br /> TkreGUllt Q�@ P t (Fill one only) (Fill allthgt�apply); (Fill all that apply) (Fltl allth to ply) <br /> 0 Active D Passenger 0 Generator <br /> Latitude – O 0 Closed 1 0,Altered <br /> GPS -` C 0 Hauler ('Indoor <br /> - _10 Inactive (�.7ruck . 1 <br /> Longitude Planned O'OTIi End Use 0 Container <br /> Business Type (FIA all�f�rA apply!!! ) — – 1 <br /> 0 New Tire Dealer 0 Auto Repair 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 /> Service Station 0 Hauler <br /> 0 Agriculture 0 Shredder Q Other , �.,t :• � , <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V FA HAULING AND MANIFEST REQUIREMENTS <br /> 0 i 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 / m / m <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 - No Violations <br /> 0 0 Other: § — - <br /> Comments <br /> r <br /> f , <br /> Ins eCommen s Included, i= ---- _ , <br /> p 0 <br /> 01 Business s 1 nature Phone Number . Inspecto,r`s Signeture � Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ' A;doh 62081 <br /> • V - T <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />