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T <br /> p --- p _ber <br /> Waste Tire Suzy & Inspection Report`_ � <br /> In ection Re ort Nurn <br /> California. State of California _ <br /> IDWSi C�IWMB181(New04r04) Survey Form - Page 1 Q 4.. _ <br /> Iifornia Integrated Waste Management Board <br /> Part A Surve BLUE OR BLACK INK PEN <br /> TPID- 11 _ <br /> Inspection Type (Fill one) <br /> Suffix: 1 � © Re-inspection Referral Q Observation <br /> SiteSuffix: �T! I � � �;Routine Q p Q <br /> Local <br /> If Referral,choose referral type(Fill one) <br /> Identifier: , � ,,y,t,;, t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `` <br /> Inspected By Inspector <br /> Physical Address <br /> L4 L <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out AM <br /> __ <br /> Business Rep Title ++ <br /> .__ 0 AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> 11 (Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger Q Generator Q Outdoor <br /> m FTT��0 Q Closed Q Altered <br /> GPS Latitude <br /> p Q Inactive QQ Hauler Q Indoor <br /> Longitude <br /> Longitude — Tl - <br /> FT <br /> 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 ` 1 HAULING AND MANIFEST REQUIREMENTS _ Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> 01 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q (a 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § _ <br /> Comments <br /> f ' <br /> 14 Al, <br /> Inspection Form Included: Q <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number _ <br /> 62_081 <br /> INSTRUCTIONS ON BACK CorrectV Incorrect: X "°..rM1� �- ` <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />