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Waste Tire SuW & Inspection Repor spection Report Number <br /> State of California A - 7 r} <br /> CIWMB 181(New <br /> Manag) Survey Form - Page 1 I -� i �V I +f. '1 <br /> California Integrated Wase Management Board - ` <br /> part A- Survey BLUE OR BLACK INK PEN <br /> Busines4IIIIIIIIIIIII nspection Details 1 <br /> TPID- r I - I Inspection Type (Fill one) <br /> Site Suffix: J J i t ` 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 <br /> Inspected By Inspector <br /> physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> �OPM I 0 P <br /> - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) � I I + I � <br /> s � ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> y) <br /> Active Passenger Generator QOutdoor <br /> Q Closed Q Altered <br /> Latitude <br /> GPS i i <br /> Q Hauler Q Indoor <br /> J Q Inactive Q Truck I <br /> Longitude - I <br /> g L <br /> .I 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 HAULING AND MANIFES t REQUIREIVIEN"I°5 <br /> --- -- 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 /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / Ffl <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/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 Q In Compliance - No Violations <br /> Q Q Other: § - <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: Q' - - - - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 'E X I AIMI P i L EI 1112131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />