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Waste Tire ey & Inspection Rep _ Inspection Report Number <br /> -� <br /> " State of California <br /> �rnia CIWMB181 <br /> Waste <br /> eManag) Survey Form - Page 1 t 2 - 1 0 1 3 1 5 0 <br /> California Integrated Waste Management Board <br /> Part A Survey BLUE OR BLACK INK PEN <br /> TPID- -7 } �. 'Inspection Type (Fill one) � <br /> Site Suffix: l� 1 ..0 /t #Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: -; 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> T <br /> ! . . <br /> Business or Facility Nam <br /> Inspected By Inspector <br /> Physical Address <br /> G� <br /> Street <br /> Inspection Date [H] <br /> / 7;7 <br /> City (� State ZIP Code Time In _ Time Out <br /> Business Rep Title 0 PM O PM <br /> Operational Status Business Role Storage Type <br /> / (Fill one only) ( (Fill all that apply) (Fill all that apply) <br /> " ® Active `'1 ® Generator 0 Outdoor <br /> GPS Latitude Closed 0 5 � 0 Hauler 0 Indoor <br /> - -- — — 0 Inactive 0 7� W �a ,,/ ' <br /> Longitude - 0Planned 0 OTR 0 End-Use 0 Container <br /> Bus!n" <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 ® Other J J <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VI A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> D <br /> 0 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 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 (S 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FFI / FFI / 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 ( ' 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 In Compliance - No Violations <br /> 0 0 Other: <br /> Comments r j <br /> r , <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business pep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />