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= Waste Tire SL ,y & Inspection Report�lnspection Report Number <br /> : :. _ <br /> State of California A A <br /> CIWMB 18ast(New <br /> Manag) Survey Form - Page 1 1 4 - 1 0_ �---0--1 l .171 <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 L� - <br /> I � r-' � 0 Routine 0 Re-inspection Q Referral 0 Observation <br /> Local r t If Referral,choose referral type(Fill one) <br /> Identifier, �i1Ct r' (l'�� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name _ Inspected By Inspector <br /> Physical Address I 11 '' I • l r <br /> l I <br /> Street _ <br /> t ! _ 4Inspection Date ' f <br /> City State ZIP Code Time In 4 Time Out <br /> 14 1. <br /> Business Rep Title 1 l Q AM 0 AM <br /> �;�• tr'Ir�L 0 P � ' � CPM <br /> Operational Status Tire Type Business Role rtorage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> 0 Active Passenger 0 Generator 0 Outdoor <br /> O aClosed 0 Altered <br /> GPS Latitude m . 1 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 0 0 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 1 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 11 0 114 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 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 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments T <br /> �� -(- - <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> X � +f�� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � � )C �, ,�, P �. � � � 3, <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />