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■ sectort Number <br /> Waste Tire Su & Inspection Report ionRe pp - _ _ � <br /> State of California <br /> CIWMB 1S1(New 04/04) Survey Form - Paged $ <br /> California Integrated Waste Management Board ----- - -- ----- --- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile ns <br /> TPID- -"' Inspection Type (Fill one) <br /> Site Suffix 'j T ' Q Routine Q Re-inspection Q Referral Q Observation <br /> Local /--- If Referral,choose referral type(Fill one) <br /> Identifier: ; Q 1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address i / 47' <br /> Street -- <br /> r- Inspection Date <br /> City - <br /> State ZIP Code Time In Time Out <br /> Business Rep Title O AM AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type w ) .,. Business Role Storage Type <br /> (Fill one only) (Fill all that'appiy)Qill all that apply) (Fill all that apply) <br /> l' L 1Q Active Q Passenger I Q,Generator Q Outdoor <br /> t <br /> GPS LatitudeED • L H=O Q Closed Q Altered.. Q Q <br /> Hauler Indoor <br /> _ Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End Use Q Container <br /> r�stne`ss 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 Collectiorj,�' Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q ShreddetV Other f __. <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 <br /> 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 / 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 I CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 10 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 /> ® 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X A�, A !4"■ ?.. I i— L. <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />