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Waste Tire Sur. y & Inspection Report nspection Report Number <br /> iLLg1 State of California <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 1 6 - 1 D 1 4 S 9 6 <br /> California Integrated Waste Management Board <br /> 'ant A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- ^� Inspection Type (Fill one) <br /> Site Suffix: Z ` ' v I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: "'> „� L ` 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address i "> — I _ ''v <br /> Street <br /> Inspection Date <br /> kD <br /> �7td / C) <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title I O AM 0 AM <br /> O PM I . I I O PM <br /> -JUi Operational Status Tire Type Business Role forage Type <br /> Tire Count (Whole/PTE (Fill one only) (Fill all that app , ((Fill all that apply) itI all that apply) <br /> 0 Active 0 Passenger 0 Generator utdoor <br /> GPS I � d I I 1) ® Closed t0 Altered 0 <br /> Latitude I Hauler Indoor <br /> lu <br /> 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTRjjjjNj 0 End-Use ntainer <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORC'EMEN 1 81AI LIS <br /> V A }HAULING Mb MANIFEST"REQU61EME'N''TS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / 0 <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments /� 1. f f <br /> / r <br /> Inspection Form tncluded` ' <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspectors Signature< Phone Number <br /> X v I Nt I I I I I I I 1 62081 <br /> E� <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � X A F L E 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />