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.: Waste Tire Sway & Inspection Repor . Inspection Report Number <br /> 01111=1State of California <br /> CIWMB1811st(New Manag) Survey Form - Page 1 10 0 7 5 0 c <br /> California Integrated Waste Management Board __ ______.__ ___.. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Q Reinspection Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Eke - L� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / <br /> Inspected By Inspector <br /> Physical Address <br /> Street A a <br /> Inspection Date t i� <br /> Dv1 1 <br /> City State ZIP C'ode Time a In Time Out <br /> Business Rep Title jAM �) 0 AM <br /> 0 PM 0 PM <br /> I Storage <br /> Operational Status Tire Type " Type <br /> The COUnt(��1Ca el f lo <br /> (Fill one only) (Fill all that a ppi1 Business Role(Fill all that apply) (Fill all that apply) <br /> LL0 Active Q Passenger Q Generator Q Outdoor <br /> Latitude - <br /> GPS <br /> - j 0 Hauler 0 indoor <br /> 0 Inactive Q Truck <br /> Longitude — LLLLE 0 Q Planned Q OTR Q End-Use Q Container <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 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 0 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 / Fn / m <br /> Q 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 /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f 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 /> � 7iKS(]okl�fl(' ►n5�'C-hon C &l " etc & 1 .W wa-s h' I e c� <br /> "a 'ori�v rc�r lry�tri()tl Il fx,,; 4ems T'r' , Qeoec,ttedr ► c : ct 1 r <br /> j -J <br /> oo Pt+ l�f I(r� ` �i�`1 �`J (t11�'?`?rbZf '� or kl)d Q S jOal-e s. N ) WO t <br /> 190o 11�po6ed of acee\f 1A , Rr6f re(c)(A of Iii(,e r-e mova is arc t'ue,,,e 6_j <br /> ection orrn <br /> Comments Inctude' <br /> Business Rep's Signature'•, hone Nurnbe <br /> ` f - <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X lPIL � IfI �I3I 62081I I� I�',X �; ,� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� <br />