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LL <br /> Waste Tire Su^ & Inspection Report nspection Report Number <br /> California <br /> 'ori: ��rate 8ast(New <br /> Mana a Survey Form - Page 1 l L - 1 01 0 5 3 5 <br /> California Integrated Waste Management Board <br /> part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details `l <br />} TPID- Inspection Type (Fill one) <br /> Site Suffix: Q 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 Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> State ZIP Cone Time In Time Out <br /> Business Rep Title I : I I I O AM I I : I I I Q AM <br /> QPM QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PT J <br /> Q Active O Passenger Q Generator 0 Outdoor <br /> U (aClosed O Altered <br /> GPS Latitude I L O Hauler door <br /> O Inactive 0 Truck <br /> Longitude — 0 Planned ,0 OTR O End-Use ontaine` <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> Q Service Station O Hauler O Agriculture Q Shredder O 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 /> Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> 7O L-Or�F_.. <br /> Inspection Form Included: <br /> Comments Included; - - - ---- <br /> Business Rep's Signature Phone Number Inspector's Signatur Phone Number <br /> - _.-.. <br /> I <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � E )(Ift MIpILEI 1112131 62081 <br /> White Copy UNNIB Yellow Copy:Operator Pink Copy:LEA <br />