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Waste Tire SL 'y 8c Inspection Repor,. . Inspection Report Number <br /> - "'• State of CaliforniaCIWMB 181 <br /> tew 04/04) <br /> Califom�Integratd Wase Management Board Survey Form - Page 1 i 5 - { V V V 4 V L <br /> Part A- <br /> Survey BLUE OR BLACK INK PEN <br /> -etails <br /> TPID- � Inspection Type (Fill one) <br /> Site Suffix: j /, Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> -all - <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title / [T 0 AM <br /> O PM O PM <br /> Operational Status a Type Business Role orage Type <br /> Tire Count (Whole/PTE) ;10 <br /> (Fill one only) (Fill all that apply) (Fill all thatappy) ill all that apply) <br /> Q Active O Passenger @Generator Outdoor <br /> FTI Q Closed 0 Altered <br /> GPS Latitude Q Hauler door <br /> Q Q Inactive 0 Truck <br /> Longitude - � Planned � OTR 0 End-Use "� Container <br /> Business Type (Fill all that ap`I � <br /> Q New Tire Dealer 0 Auto Repair 0 Trucking Fleet Q Government Q Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> 0 Service Station Q Hauler Q Agriculture Q Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O 0 PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O in Compliance - No Violations <br /> Q O Other: §` <br /> Comments <br /> Inspection Form Included: O <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature. Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E X A MI I P I L 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> s <br />