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v ► Inspection Report Number <br /> � WasState of ,teaTire Sibley & Inspection Repor� p ___-p -___ _ <br /> �� CIWMB18ast(New <br /> Manage) Survey Form - Page 1 ! 8 - 1 1 0 n <br /> California Integrated Waste Management Board __ -_ <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business-Profile Inspection Details <br /> TPID- i ( I - I I I I Inspection Type (Fill one) <br /> Site Suffix: <br /> Q Routine Q Re-inspection Q Referral Q Observation i <br /> Local ; If Referral,choose referral type(Fill one) <br /> Identifier: <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name t.' <br /> Inspected By Inspector <br /> f' i m <br /> Physical Address J <br /> LSI I 1 r <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title0 AM Q AM <br /> 0 PM Q PM <br /> Operational Status Tire Type Business Role torage Type <br /> r (Fill one only) (Fill all that appy (Fill all that apply) Fill all that apply) <br /> Tire Count (Whole/, <br /> ® Active Q Passenger Q Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (= �I <br /> Q New Tire Dealer Q Auto Repair ® 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 <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB FF <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 IQ 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 I 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 /> r � <br /> (JI biI <br /> 4 tl✓ !d �,(. <br /> k'l o 0-1 )'y(d Iyy Jl <br /> � <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 V r- ' p ;+, pTF <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />