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:- Waste Tire Su & Inspection Repor nspection Report Number <br /> �. State - - - <br /> Eforn B 81 st(New nage Survey Form - Page 1_ � 1 t_ � -0 �_--4 � 9- 7 <br /> California Integrated Waste Management Board <br /> Part A Surve BLUE OR BLACK INFO PEN <br /> Inspecfan I % r,..:, - - <br /> TTn'!", <br /> Inspection Type (Fill one) <br /> Site Suffix: � � r� ,! �7 / �-- <br /> 6 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 /> Business or Facility Name - <br /> r' <br /> - Inspected By Inspector <br /> Physical Address <br /> Sten-et._ <br /> Inspection Date <br /> \ i Time In Time Out <br /> City -- State .ZIP Code _ -__ <br /> Business Rep Title O AM <br /> 0 AM <br /> t <br /> 0P ' � QPM <br /> Operational Status Tire Type,d� +�fr Business Role Storage Type <br /> (Fill one only) (Fill all that apply, (Fill all that apply) (Fill all that apply) <br /> lad" F � r �r�f ➢+"� � JE <br /> Imam <br /> } Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> -— Q Inactive 0 Truck <br /> O <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <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 Q Other %f r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 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 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date111111 <br /> / <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB MW <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 (5 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 J _ y <br /> Inspection Form Included: 0', <br /> Comments Included: _- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X V A ,��I I_ L <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br />