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j{ <br /> ® to Tire Su & Inspection Report aspection Report Number <br /> a� ■ <br /> `=°I ate of C ifornia <br /> °" Survey Form - Page1 1 8 - 1 GO65 ^ <br /> IWMB 1 (New 04/04) �y <br /> California In grated ste Management Board V` <br /> Part A- Surve'f - --_ BLUE OR BLACK INK PEN <br /> Business Profile _ Inspection Details - <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: - <br /> ® Routine O Re-inspection Q Referral Q Observation <br /> Local <br /> - <br /> Identifier: If Referral,choose referral type(Fill one) <br /> Q CHP Q CIWMB Q Complaint 0 Educational Visit O Other <br /> Business or Facility Name <br /> _`` Inspected By Inspector <br /> Physical Address _ O 1 <br /> Inspection Date / / / 05 <br /> Business Rep Title Time In Q AM Time Out <br /> O AM <br /> er-2 I� 1 Q PM 0 PM <br /> er Operational Status' Tire Type F__ <br /> s Role Storage Type <br /> Tire Count Whole/PTE (Fill one only) (Fill all that apply) at apply) Fill all that apply) <br /> � 1 � PPY) ( PP Y) <br /> - - <br /> ® Active Q Passengererator O Outdoor <br /> GPS Latitude O Q Closed Q Altered <br /> Q Hauler O Indoor <br /> O Q Inactive Truck <br /> Longitude _ <br /> Q Planned O OTR O End-Use O Container <br /> ----- --- -- -- ------- <br /> Business Type (Fill all that apply) - - — —- -- - -- - -- --_New Tire Dealer Auto Repair Trucking Fleet Government - Dismantler -- d Fuel— erve <br /> Q <br /> Used Tire Dealer O Auto Body 0 Car Dealer Q Collection O Crumb Rubber <br /> Q Seryice Station O Hauler O Agriculture Q Shredder O Other <br /> art B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> acilit ENFORCEMENT STATUS <br /> A HAULING AND MANIFEST REQUIREMENTS I - �<« <br /> D O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> I <br /> J O PRC§42953-Contracts with Registered Waste Tire Haulers. it <br /> Compliance Deadline <br /> O PRC§42956-Registration/Decal in Vehicle i <br /> Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> Date m m m <br /> 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EX7) <br /> D O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> -- -- - — i <br /> Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f CIWMB Enforcement <br /> Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O Other: § 0 In Compliance No Violations <br /> Comments - ---- <br /> �c�e��— <br /> � �-- �-� _lam _�-mss--� ���1���� �,,- _�►�_-. <br /> __--NOAv �`111A <br /> spection Form Included: Q <br /> r <br /> Comments Included: Q <br /> Business Rep's Signature <br /> - - <br /> - -- - _-_ g Phone Number Ins ctor' Phone Number ff <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ( 62081 <br /> • _ � V X thh F L f 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />