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Waste Tire Su°*y & inspection ReporA_lnspection Report Number ■ <br /> State of California I 10 8 A <br /> CIWMB181 New 04104) Sl.Jrve Form - Pa e 1 l <br /> California Integrated Waste Management Board Y g <br /> Part A- SVey BLUE OR BLACK INK PEN <br /> -- - <br /> r r' Inspection Details <br /> ( Inspection Type (Fill one) <br /> SiteTPI - 1J _ <br /> Site Suffix. ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: :' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> _ _ - <br /> Business or Facility Name t <br /> Inspected By Inspector <br /> Physical Address l L•' / i f -'•� <br /> 4� <br /> Street <br /> Inspection Date <br /> c.te ZIP C©de`i Time In Time Out <br /> State _._.. <br /> Business Rep Title O AM O AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage.Type <br /> The GOUnt(V�bole/PTL) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger Q Generator Q Outdoor <br /> r1�L <br /> }� O Q Closed Q <br /> GPS Latitude W , rryrt Q Hauler Q Indoor <br /> O Q Inactive Ql� � <br /> Longitude - Q Planned Q OTR Q End Use Q Container <br /> n <br /> _..I <br /> si v Type (Fill all'0i,papply) <br /> Tire Dealer Auto Repair Q Trucking <br /> Awa+ f <br /> Fleet 0 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 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 <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 @ 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 t 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 /> I - <br /> Inspection Form Included: Q <br /> Comments Included: Q _ <br /> Business Rep°s Signature Phone Number Inspector's Signature _-__ _ ,Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X /P 1,/ i;,A ?hij r" L)4; <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />