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Waste Tire Su , & Inspection Report nspection Report Number <br /> -ID&71. State of California <br /> r CIWMB 18ast(New Manag) Survey Form - Page 1 1 5 - 1 0 7 5 <br /> California Integrated Waste Management Board - - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: j �) L) 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 /> f <br /> Business or Facility Name -: <br /> Inspected By Inspector <br /> Physical Address <br /> ' Street <br /> Inspection Date <br /> State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> m � m0PM � ' 0 P <br /> -- Operational Status Tire Type Business Role Storage Type <br /> TireCount (WholelPTE f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / (D Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude � , FT 0 Hauler 0 Indoor <br /> - = d O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <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 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 1 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive 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 ). n , T. f i <br /> i <br /> Inspection Form Included: 0' <br /> Comments Included: 0 -- --' - _ <br /> Business Rep's Signature Phone Number Inspector's§jgnature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X f.= .4 OPz <br /> E T I� 62081 <br /> . <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> I <br />