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Waste Tire Su. . y & Inspection Report nspection Report Number <br /> Cd7' State of California i . <br /> Califom>�Int grat dt81 Waste Management Board Survey Form - Page 1 ��1 ! t 10 2 5 6 5 4 <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> nspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ✓ n L� -� Q Routine Q Re-inspection Q Referral Q Observation <br /> Local — If Referral,choose referral type(Fill one) <br /> Identifier: I J 43". Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> _r <br /> Physical Address <br /> Street <br /> ef::_- f/ v 1� Inspection Date <br /> ( ice', <br /> State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> O PM � I ' I O PM <br /> Operational Status Ire TypeBusiness Role orage Typ <br /> Tire Count (Whole/PTE; (Fill one only) Fill all that apply) (Fill all that apply) ill all that ap <br /> Active Q Passenger Q Generator Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> � Q Inactive Q Truck <br /> Longitude – Q Planned Q OTRto End-Use Q Container <br /> t, <br /> Business Type (FIg„,: : <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 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date FP / m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 0 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 Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § II 1 <br /> Comments f / <br /> I��t , - � /Cz/�7� -7lni' f-r � d_'� -7 1__' {[� <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's_ Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E XI A Ill I L I EI 11.12131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />