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■ nsection Report Number <br /> T _ Waste Tire Su�y & Inspection Repor pp_ <br /> State of California n <br /> " <br /> as CIWMB 04104 <br /> California Integrated Waste ge)ment Board Survey Form - Page 1 , -0 3 5 3 <br /> — --- - - -- - <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: , f -� / <br /> (�...-' (D Routine Q Re-inspection Q Referral Q Observation <br /> Local r— �) If Referral,choose referral type(Fill one) <br /> Identifier: _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> IS.. <br /> Business or Facility Name i' <br /> Inspected By Inspector <br /> <' <br /> f tic �i . ,1. ...<� 1 <br /> Physical Address <br /> ty ;+ <br /> Street/ Inspection Date ~? E/E FR <br /> City State ZIP Code Time In _ Time Out <br /> Business Rep Title 0 AM O AM <br /> Q PM < 0 PM <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 /> Tuve Count (lAfhole/PTS') <br /> ' (g) Active Q Passenger Q Generator Q Outdoor <br /> (�1 O Q Closed Q Altered <br /> GPS Latitude _EE <br /> � •LLLii� Q Hauler Q Indoor <br /> _ C Q Inactive Q Yuck <br /> Longitude — Q Planned Q OTR O End-Use Q Container <br /> "'I", J <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 <br /> HAULING ANMANIETREQUIREMENTS <br /> QRMEN ds O Notice Of Violation Q Extension <br /> O O AND <br /> eHaler RegistrationTransport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / <br /> m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 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 Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q O (Other: § <br /> Comments <br /> - <br /> Inspection FormInclude r <br /> + .n... "r"r � N, «^ t + b Y y r ".'P -u`+«„ w, M+ , , .+ .(l.^ Mf'Y';�.t ✓utu, %�nsr ,°�d <br /> Comments Included: Q <br /> Business Reps Signature. Phone Number inspector's Signature PFaolae Number <br /> Lr� 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X "!� L;W 'N. i_ 11121-3] <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� ■ <br />