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Inspection Report Number <br />Waste Tire Su&y & Inspection Repor , --- <br />o;< <br />State llSurvey Form -Page 1 i - 0 i 0 <br />CIWMBMB1818(New 1 (New 04/04) <br />California Integrated Waste Management Board — - <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - � Inspection Type (Fill one) <br />Site Suffix:% / - <br />� � Q Routine Q Re -inspection Q Referral Q Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name Inspected By Inspector <br />j,:- ; i, 1 i''I <br />Physical Address <br />Street - - <br />City <br />Business Rep <br />Tire Count (Whole/PT <br />Inspection Date ,r <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />State ZIP Code Time In <br />Title <br />OAM <br />Time Out <br />0 AM <br />Q <br />m <br />' 0 PM <br />Q <br />0 PM <br />Q <br />Operational Status Tire Type <br />Business Role <br />Storage Type <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 />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />QO Active <br />Q Passenger <br />Q Generator <br />Q Outdoor <br />Q Closed <br />Q Altered <br />FT <br />I I <br />Q Hauler <br />Q Indoor <br />O Q Inactive <br />Q Truck <br />I I Q Planned <br />� Q OTR <br />Q End -Use <br />Q Container <br />Trucking Fleet <br />Q Government Q Retreader <br />b Rubber <br />Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crum <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 i 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 with 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 fi <br />Q 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 />Inspection Form Included: Q <br />Comments Included: Q -- --- - - -.. - <br />Business Rep's Signature Phone Number Inspector's Signatur Phone Number <br />INSTRUCTIONS ON BACK Correct:* Incorrect: X L 3 62081 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />