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.pWaste Tire Su & Inspection Report_ pe_ction_ Re ort Number <br /> � <br /> State of California ! ``t s t <br /> California Integrat dCIWMBf WasNe Management Board Survey Form - Page l U a <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> i��StneSS P,rc7'(wl(�t� , rispection �aM `r��:. ------- <br /> TPID- ++ Inspection Type (Fill one) <br /> Site Suffix: E Q Routine Q Re-inspection Q Referral Q Observation <br /> - - <br /> Local u� If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> Physical Address t i <br /> Street (` <br /> Inspection Date <br />� <br /> Cit <br /> t State ZIP Code Time In O Time Out I T___.. <br /> Business Rep Title AM AM <br /> � 0 P � �.__9 0PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) s ' (Fill one only) (Fillthat <br /> sen apply)! <br /> Generator Outdoor <br /> all (Fill all that apply) (Fill all that apply)I <br /> Q Active 0 Passenger 0 0 <br /> 0 Q Closed Q Altered <br /> PSLatitudeG . L �� ___ <br /> Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q 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 <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred t CIWMB Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> ,Inspection Form Included: Q' <br /> Comments Included: Q - - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X Ak IVE X A ihF f �_ 1 a L 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />