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Waste Tire Sur _ y & Inspection Report ,\ ispection Report Number <br /> _;;�, State of Survey Form - Page 1 i 1 1 G 1 3 3 S a <br /> CIWMBB181 Californiaf New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- 1-61 <br /> Inspection Type (Fill one) <br /> Site Suffix: d -7 C I 17r 1 , Routine Q Re-inspection 0 Referral Q Observation <br /> Local - /�"' If Referral,choose referral type(Fill one) <br /> _-- <br /> Identifier: >,:- Cr, ,J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> ---- <br /> Business or Facility Name Inspected By Inspector <br /> Ph y sical Address <br /> Inspection Date <br /> City State ZIP Code Time In _ Time Out <br /> Business Rep Title ; O AM Q AM <br /> 0P QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> ' (Fill one only) (Fill aEl that apply)' (Fill all that apply) (Fill all that apply) <br /> Tire COUnt(Whole11W/PTE) 17717 <br /> ii" Q Active 0 Passengerw` Q Generator Q Outdoor <br /> ® Closed 0 AlteredLatitudeGPS . EEO 0 Hauler d Indoor <br /> 0 Q Inactive 0Truck <br /> Longitude — Q Planned O OTR ,,, O End-Use O Container <br /> �t <br /> Wo New Tire Dealer o Auto Repair Q Trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> Q Service Station O Hauler O Agriculture Q Shredder O 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 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ -- <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> O O Other: § ------- ----------------- <br /> �� <br /> Comments <br /> Inspection Form Included: QI <br /> Comments Included: Q `- <br /> Business Rep's Signature Phone Number .In�ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X tlJX A, MP I. 1 j 1 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />