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Waste Tire Su. ,y & Inspection Report juspection Report Number <br />E9G7E. State of CaliforniaClWMB 04/04) <br />�/�j �/�j <br />California Integrated ittllas eeManagement Board Survey Form - Page 1 R y - 10 1 �f{ 0 i 6 �41 <br />A- Survey BLUE OR BLACK INK PEN <br />TPID - <br />Site Suffix: <br />� I A 1 -9 1 ci -19 1 / E -N] <br />Local y <br />Identifier: <br />Business or Facility Name 1 <br />inspection Details <br />Inspection Type (Fill one) <br />® Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />_ lj Inspected By Inspector <br />Physical Address J rf <br />1 Inspection Date <br />I I I Time In <br />City State ZIP Code Time Out <br />Business Rep Title O AM O AM <br />I m'mOPM m' OPM <br />Operational Status Tire Type Business Role[:1 I forage Type <br />(Fill one only) (Fill all that apply) (Fill all that apply) all that apply) <br />Tire Count (Whole/PTE <br />0 Active Q Passenger Q Generator utdoor <br />O Closed Q Altered d <br />GPS Latitude <br />Q Hauler Q Indoor -CTI O Q QTQInactive ruck <br />Longitude lOQEnd-Use Q Container <br />anned TR�A <br />P <br />usiness' all that <br />Q New Tire Dealer Q Auto Repair (& Trucking Fleet Q Government Q Retreader <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 <br />V ! A HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts wi;h Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />Other: § <br />Comments 25 d <br />is tt <br />t f <br />Inspection Form Included:' <br />Comments Included: Q <br />Dismantler Q Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />Q In Compliance - No Violations <br />U ttT r t� r 0 �(t.A <br />Business Rep's Signature Phone Number Inspector's Signature <br />INSTRUCTIONS ON BACK Correct:0 Incorrect: X I E__XjA, ."AFP (1. 1 2 3 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />Lj,I' <br />Phone Number <br />62081 <br />