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Waste Tire Su, . y & Inspection Repor spectionReportNumber <br /> ••�II � State of California t /t . /0 3 1 <br /> Cgrated Waste <br /> Survey Form - Page 1 1113 /j (-_ .it <br /> California Integrated Waste Management Board - __ <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detail <br /> TPID- + � 1 � Inspection Type (Fill one) <br /> Site Suffix: 1 /r- il: ! r 1 (0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �-- � ,-- 'if Referral,choose referral type(Fill one) <br /> Identifier: I <br /> Q CHP O CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name v P Inspected By Inspector <br /> Physical Address <br /> --z 5 �- <br /> � / � J l.^ — <br /> Street Inspection Date <br /> State ZIP Code� Time In Time Out <br /> City <br /> Business Rep Title AM O AM <br /> � • 0P 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PT <br /> ® Active Q Passenger !, Generator Outdoor <br /> Q Closed 0 Altered <br /> FFT <br /> GPS Latitude m • Q Hauler O Indoo, <br /> D 0 Inactive 0 Truck , <br /> Longitude — Q Planned 0 OTR O End-Use O Container <br /> _... _.__ <br /> a at'ap - <br /> ® New Tire Dealer Q Auto Repair O Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station Q Hauler O 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 /> Q 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 O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> O O 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 /> 0 O Other: § <br /> Comments - <br /> P- ' - -- <br /> Inspection Form Included: O <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK CorrectV Incorrect: X `� , ,µ PME1 I Z ! 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />