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Waste Tire SAIvey & Inspection Repo, . Inspection Report Number <br /> State of California <br /> Cgrated 1steManage Survey Form - Page 1 ! 2 - <br /> Calitornla Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Pro_f_lle Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By inspector <br /> Pfiyslca cess`rCwlr\—`t ?j C� — o.w�a5 <br /> l `f <br /> Inspection Date <br /> � <br /> Time In Time Out <br /> i Business Rep Title i O AM O AM <br /> O PM O PM <br /> I <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill ail that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> D I 10 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O + Q Inactive Q Truck <br /> Longitude — 1 Q End Use Q Container <br /> Q Planned Q OTR <br /> i <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 NFORCEAAENT 87A7US <br /> f A I.MAULING:AirD MAN IPESTANQUIREM[41NTS i 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. I Compliance Deadline <br /> Q I Q PRC§42956-Registration/Decal in Vehicle <br /> IQ Q 14 CCR§18459 - Responsible Entities Complying with Manifesting Requirements Ditty <br /> Q Q 114 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q !I Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EX7) <br /> Q ! Q 114 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 Rif erred/`CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators II <br /> IB 0tvp!llsng4 .No Vloletiotn <br /> Other: § <br /> Comments <br /> Inspection Form Included: Q376�� <br /> Comments Included: Q' <br /> Business Rep's Signature Phone N{uum�berC sp ignature Phone Number <br /> _... j ! A ,h �-� i L'12 62081 <br /> INSTRUCTIONS ON BACK ({ CpPI`�I�f ;r:. lV,; ' <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />