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�_�; Waste Tire Sur�,.y & inspection Report Inspection Report Number <br /> •llr Stats B California + A i <br /> CIWMB 18asteMana a survey Form - Page 1 U `I <br /> California Integrated Waste Management Board <br /> 'art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile U 1 b b Q <br /> -f ! i4 0O 84 � InspectionLUDetails <br /> TPID- Inspectlolf <br /> :] o=nSite Suffix <br /> : I O ® Routine e-in� <br /> ,3: - - - <br /> Referral 0 Observation <br /> Local If Referral,=chocsb:fefgrral type ill{spe) <br /> Identifier: :AMS O CHP I I�%ItR��PdiQ�,ta�r>malnt Q Educational Visit Q Other <br /> Business or Facility Name Inspected B ��r <br /> P y Inspector <br /> CAI <br /> eL <br /> Physical dress <br /> Street <br /> lP <br /> Ins ection Date <br /> City State �ZJP Code Time In Time Out <br /> Business Rep Title <br /> l ®AM 1 AM <br /> L\ v b O <br /> PM L1 1 ' A E) PM <br /> - � Operational Status Tire Type Business Role - Storage Type <br /> I r <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �� , I I t 1 1S �p <br /> (� T— Q Active 0 Passenger ® Generator ® Outdoor <br /> Latitude I 1'1 1 I I� D 0 Closed (�Altered <br /> GPS � I f• I_ _{ Q Hauler Q Indoor <br /> i r^�_T �.O O Inactive 0 Truck <br /> Longitude I , I ! i I o Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair 0 Trucking Fleet Q Government O Retreader O Dismantler Q Tire Derived Fuei <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station O Hauler Q Agriculture Q Shredder ® 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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 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 /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred!CIWMB Enforcement <br /> Q 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O ® 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> O 0 Other: § <br /> Comments , r <br /> a, <br /> n� _Ln� 5 <br /> Inspection Form Included: Q c / <br /> 4119np4ureComments Included: 0Bu ness RPhone Number Ins ector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: X( 1 EV AIM P I L i E 1 1112 31, 62081 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />