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Waste Tire Suky & Inspection Reporm_Inspection Report Number ■ <br /> State of California <br /> Califoma0Integrated WaseManagement Board i � 100 VCIWMB 181 ew 04104) Survey Form - Page 1 J <br /> d i <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile spectirn 0efaa <br /> TPID- / _ � Inspection Type (Fill one) <br /> I <br /> Site Suffix. I i / I 0 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 Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date <br /> City State Z!P Code Time In Time Out <br /> Business Rep Title OAM 0 AM <br /> m � 0 P EL QPM <br /> I- V <br /> Operational Statusl '"F Business Role Storage Type <br /> r io���r <br /> (Fill one only) (F(" (7 ( ` (Fill all that apply) (Fill all that apply) <br /> i <br /> , <br /> 0 Active ( 95Yt%I 0 Generator 0 Outdoor <br /> Latitude <br /> — — <br /> D 0 Closed �d { f",fit," " <br /> GPS 0 Hauler 0 Indoor <br /> 0 Inactive <br /> D <br /> Longitude — (� OTR 0 End-Use 0 Container <br /> Planned <br /> 0 New Tire Dealer LLD 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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 1 A j HAULING AND MANIFEST REQUIREMENTS <br /> - -- 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 Date M / M / 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 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § — --- — -- -- ---. -._.: <br /> Comments <br /> Inspection Form Included. <br /> Comments Included: 0 - <br /> Business Rep's Signature Phone Number inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X ', =' p <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />