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Waste Tire Su#y & Inspection Reporlo Inspection Report Number <br /> ka CIWMB 811(New04/ Survey Form - Page 1 l 9 - 1 01 0682 <br /> Cgement Integrated Waste Mana <br /> gement Board rd - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r,: �- i Inspection Type (Fillone) <br /> Site Suffix: F J J - 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: w ( 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name t_ <br /> / Inspected By Inspector <br /> 0 L4 <br /> Physical Address - <br /> i <br /> i <br /> Inspection Date <br /> Business Rep Title <br /> State ZIP Code Time In Time Out <br /> FOAMm m 0 AM <br /> 0 P �I � L 0PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/P (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> T A <br /> Active 0 Passenger i 0 Generator 0 Outdoor <br /> Latitude <br /> O @ Closed 0 Altered <br /> GPS m . <br /> I <br /> O 0 Inactive 0 Truck 0 Hauler 0 Indoor <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 In Compliance - No Violations <br /> 0 0 Other: § — -- <br /> Comments <br /> - <br /> I <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> - � - <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X /P \/ L XI A MI w 1 L 1 E i 1 2 3I 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />