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Waste Tire Su&y & Inspection Reporl*I port Number <br /> ction Re <br /> 0772. Stale of CaliforniaC,WMB 181 04104) <br /> California Integrated Was eeManagement Board Survey Form - Page 1 I— l- V Q - 10 <br /> 13 5 6 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> nspection Details <br /> TSite SuffixPID- Inspection Type (Fill one) <br /> : - 5 `i ( G Routine Q Re-inspection Q Referral Q Observation <br /> Local (1 / If Referral,choose referral type(Fill one) <br /> Identifier: s!Cd�' r' j O CHP Q CIWMB O Complaint O Educational Visit Q Other <br /> _ <br /> Business or Facility Name (\� Inspected By Inspector <br /> J".( <br /> Physical Address C-1 <br /> Street <br /> --r-- v{� _74 <br /> �� �`� � .�� Inspection Date <br /> I �� I i Time In Time Out <br /> City State ZIP Code _ _ _ <br /> Business Rep Title O AM O AM <br /> �1 0PM m ' 0P <br /> IAC 1 r r ct <br /> Operational Status Tire Type Business Role orage Type <br /> ire Count(Whole/PT 0 or� (Fill one only) (Fill all that apply) (Fill all that apply) ill all that apply) <br /> Active 0 Passengers Q Generator Outdoor <br /> Latitude <br /> O Closed 0 Altered <br /> GPS m <br /> •' <br /> 0 Q Inactive Truck 0 Hauler Indoor <br /> Longitude – Q Planned OTR O End-Use O Container <br /> Ype ,. tt <br /> !` ® New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> t 1 <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 A HAULING AND MANIFEST REQUIREMENTS <br /> O O — 0 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers, Compliance Deadline <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> r0 O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O ' 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O i 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 O Referred/CIWMB Enforcement <br /> O Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> Q 0 (Other: § <br /> Comments 61 _ � I ) <br /> 14 C�C' TIlG 11t�iN o S n .v <br /> (;.t :i 1 ({' f> � .( �,JiG r.P (1� (t.` t ( (✓ S •(Ji/l1�C�t �C1(y� 1 r- <br /> 1 " Ttf<-c". Qc,,Y-of? 5 6/-e <br /> (OW L✓�''� J fCr t <br /> Ll fe Q �(�G1ha 1,k t' /h ri--ha —� ' <br /> p O <br /> Ins ection Form Included: <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's(Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X _E X A 141 P I L I El 1112 3 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />