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_ .AL <br /> _A Waste Tire Suoy & Inspection Report4nspection Report Number <br /> 6�' State of California <br /> Aka CWMB Waste <br /> eManag) Survey Form - Page 1 1 - 1 Q 0 6 3 3.41 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br />� TPID- Inspection Type (Fill one) <br /> � <br /> Site Suffix: ,SII Q 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 /> Busin?essslity N <br /> Business or Faciame Inspected By Inspector <br /> Physical Address ( <br /> Street - <br /> / Inspection Date <br /> I4 1 <br /> City State ZIP Code Time In Time Out <br /> Business Rep / Title 0F1 AM O AM <br /> / 0 PM O PM <br /> Operational Status ire Type Business Roleforage Type <br /> Tire Count (Whole/PT <br /> (Fill one only) all that apply)' (Fill all that apply) fill all that apply) <br /> 0 Active Passenger 0 Generator Outdoor <br /> f177YO ® Closed 0 Altered <br /> GPS Latitude � . �� 0 Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 End-Use Container'' <br /> g 0 Planned 0 OTR <br /> i Business Type (Fill all thatapply) <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 0 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 /> - - - _- 0 Notice Of Violation 0 Extension <br /> 0 I 0 <br /> 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 <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 <br /> 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> r <br /> in <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Sig_natur Phone Number <br /> 62np,,1 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X E` X�A A P L 12 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />