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■ Waste Tire SuSy & Inspection ReporInspection Report Number <br /> • .119 � State of California <br /> CIWMB01) <br /> 181 <br /> Waste <br /> eManage) Survey Form - Page 1 l 1 -0_1 a_61 1__! <br /> _. California Integrated Waste Management Board ._._._..__ <br /> Part A- Survey_________ BLUE OR BLACK INK PEN <br /> -- . . <br /> Business Profile Inspectjc,p 1?et l) <br /> TPID- 7 / Inspection Type (Fill one) <br /> Site Suffix: / i �I Z/ �, ' if Routine O Re-inspection O Referral O Observation <br /> Local —�— If Referral,choose referral type(Fill one) <br /> Identifier. , " <� O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name u <br /> Inspected By Inspector <br /> Physical AddressLDI <br /> Sti eei <br /> Inspection Date <br /> City �i State ZlP Code Time In _ Time Out _ <br /> "Business Rep Title f Q AM Q AM <br /> Q PM j ; QPM <br /> E ] __ <br /> I I <br /> I - _ <br /> t;Operational Status Tire Type Business Role Storage Type <br /> n{ <br /> Tloun (Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply)?', <br /> re'Gt� t�oi`elPT��''" .;' ,���' <br /> ., Active 0 Passenger 0 Generator O Outdoor <br /> D O Closed O Altered <br /> GPS Latitude EE - ET-1 <br /> O Hauler O Indoor <br /> _O O Inactive O Truck <br /> Longitude - -Y- o O Planned 0 OTR O End Use Container <br /> /`ill:!R That apply)., <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station Hauler 0 Agriculture O Shredder O Other <br /> Part B - Inspection o Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V i A HAULING AND"MANIFEST REQUIREMENTS <br /> O Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Regisfration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O O Other: § ----- <br /> _ <br /> Comments <br /> Inspection Form Included O.ry <br /> Comments Included; O <br /> , <br /> Business Rep - Signature Phone Number " <br /> Rep's Signature Phone Number Inspector's <br /> .: _. . <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: X � � I � �, ,a��, i. i 62081. <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />