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Inspection Report Number <br /> Waste Tire arjey & Inspection Rept <br /> �« State of California <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 - 1 - 8 - 1- 0 i _4 7--_I- <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: L 1 Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: t � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> t <br /> Physical Address <br /> Shf;-e. p <br /> Ins ection Date <br /> �- <br /> City State� ` � ZIP Code I Time In Time Out <br /> Business Rep Title AM Q AM <br /> ' �0PM m • m QPM <br /> Operational Status Tire Type a Business Roleforage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply)` (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> —�— <br /> GPS Latitude Q Closed Q Altered <br /> W . <br /> Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OT Q End-Use Q Container <br /> IAN <br /> at apply <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 A HAULING AND MANIFEST REQUIREMENTS <br /> 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 M / 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 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 />,t <br /> NEW— <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 A�, '-/ E,X4 A, M p L 11[2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />