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Waste Tire Survey & Inspection Report Inspection Report Number <br /> m <br /> State of California <br /> CIWMB 181tt1eManage) Survey Form - Page 1 I 9 - 1 01 4 7 8 2 <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: I 2 1(j 10 ' 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local /I'� ��' If Referral,choose referral type(Fill one) <br /> Identifier: C�� . J� Nor � - Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> O PM O PM <br /> Operational Status Tire Type Business RoleStorag <br /> e Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f r l®Active ® Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® 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 /> - <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires r0 Notice of Violation0'= t64it�tf <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance pe�dllns <br /> Q Q !PRC§42956-Registration/Decal in Vehicle rn <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program 10 Number from CIWMB L L 1 4 <br /> Q 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requa,9dforNOt�gr: X7� <br /> Q 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 Q-Re i7#d r CIWMB fl GC pR�kJ 'r <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 ,Other: <br /> i- <br /> Comments <br /> row 1` <br /> D41 P3&2-q - ..;_rWs4- M`*_ 1 -)51335- <br /> 4 <br /> -)5 1335- <br /> Inspection Form Included: <br /> Comments Included: - — ✓ _ <br /> Busine Rep's Signature a Number Inspe 's Signature Phone Number <br /> _ . - -- <br /> !: X R IJI P L 1= I Z <br /> INSTRUCTIONS ON CK Correct. In t: 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />