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Waste Tire Su .y & Inspection Report _ Inspection Report Number <br /> State of California <br /> �r = <br /> CIWMB Waste <br /> eManag) Survey Form - Page 1 1 3 . 100636 1 <br /> California Integrated Waste Management Board Y "�J' - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- - -. � Inspection Type (Fill one) <br /> Site Suffix: \ �j } I , Q Routine Q Re-inspection Q Referral Q Observation <br /> Local .- If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP QCIWMB QComplaint QEducational Visit QOther <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In _ Time Out <br /> Business Rep Title _ O AM 0 AM <br /> _ %rl 0 P 0 P <br /> Operational Status Tire Type Business Role orage Type <br /> al(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE' h" <br /> Active Q Passenger Q Generator Q Outdoor <br /> GPS <br /> Latitude m C 1 Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> .0 Q Inactive Q Truck <br /> Longitude - T7 - 1 10 Planned Q OTR _ Q End-Use Q Container <br /> Business Type (Fill all that apply) T <br /> Q New Tire Dealer Q Auto Repair Q 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A ''i HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 Fn / 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 1 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: Q' <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature__ Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X 4,. 'V ,,',A M FP � I F � � � �j 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />