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_ _= Waste Tire Su. y & Inspection Report nspection Report Number <br /> �"' State of California 1 <br /> •rte CIWMB 181(New <br /> Manage) Survey Form - Page 1 L_. R 1 - 1 0 2 5 0 2 4 <br /> California Integrated Waste Management Board <br /> Part A. Survey BLUE OR BLACK INK PEN <br /> Spec on Details <br /> TPID- --^7 I� � Inspection Type (Fill one) <br /> I Site Suffix: l -- / I r, - ' Q Routine Q Re-inspection Q Referral Q Observation <br /> Localf, If Referral,choose referral type(Fill one) <br /> Identifier: -"` �_! - ! 1Z Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> r <br /> war , <br /> Physical Address t / 7 <br /> 12�� 1� <br /> Street <br /> Inspection Date <br /> Cit�v State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> �- ) m � m0PM m � 0 P <br /> 40 <br /> tj Operational Status Tire Type Business Role orage'Type <br /> 3 (Fill one only) (Fill all that apply) (Fill all that apply) Fill all that apply) <br /> Tire Cuunt(Whole/ TE) cz"l <br /> 0 Active Q Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered <br /> Latitude md 1 <br /> GP$ Q Hauler Q Indoor <br /> - Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR <br /> Q End-Use Q Container <br /> Q New Tire Dealer Q Aut Repair Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto1Pody Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q 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 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 /> Inspection Form Included: O <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X P L I El 112 13 <br /> White Copy:CIWMB Yellow Cour O;.e�a-��r Pink Copy:LEA <br />