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Waste Tire SL ,y & Inspection Repor Inspection Report Number_ <br /> LHS StateBCalifornia 1 Survey Form - Page 1 7 0 � <br /> CIWMB 1 a New 04104 <br /> California integrated Waste Management Board _—.i <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> 7it <br /> D _ Inspection Type (Fill one) <br /> Suffix: v 1 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 /> Physical Address <br /> Street <br /> Inspection Date <br /> City T State Zip Code Time In Time Out <br /> Business Rep Title ®AM O AM <br /> / 0PM m • � OPM <br /> Operational Status Tire Type Business Role —Storage Type <br /> The Count (Whole/PT F� (Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply) <br /> jLAJ <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned O OTR Q End-Use Q Container <br /> Q New Tire Dealer Q Auto Repair (D 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 Q Other L <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A ?HAULING AND MANIFEST REQUIREMENTS <br /> --— <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 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 / M / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: <br /> P QI <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signaturephone.Number <br /> -- — <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X i= X(R 10,11 P E 11 2 3 <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />