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_119 A,- ,a.. -jam <br /> Waste Tire Suoy & Inspection Repor Inspection Report Number <br /> -y° State of California <br /> �r $ <br /> CWMB Waste <br /> eManag) Survey Form - Page 1 1 3 - 1 0 1 0 6 4 4 <br /> California Integrated Waste Management Board <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br />} TPID- + r I - I / Inspection Type (Fill one) <br /> Site Suffix: I >: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: i„r.r•: , (' j Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name i Inspected By Inspector <br /> Physical Address I j - j J J <br /> Ro5 Lo <br /> r }�, Inspection Date 0 I O I /tJ� / I o t/ <br /> L/ <br /> f State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> r I O PM O PM <br /> Operational Status Tire Type" Business Role Storage ype-" <br /> Tire Count (Whole/PTD (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> O ® Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude I . I I I v Q Closed Q Altered Q Hauler Q <br /> Indo <br /> � Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business T y/e (Fltl all^that a " ' <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 MANIFEST REQUIREMENTS <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 <br /> M / M / 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/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: § _dL <br /> Comments !j t •f�U I V� [ (v'l IcjAtli <br /> - <br /> "`. -�1r PJ e lTk SW � o 71, -pr rol✓Po'd <br /> r` �, U / <br /> nspeet on orm Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspecto Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X E XI A MI P f I L I EI I t 12 13 62081 <br /> White Copy:CIWMB Pink Copy:LEA <br />