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I� 1 �356�50010 <br /> Waste Tire Survey & Inspection Report. insPection Report Number <br /> err. ■ <br /> �r State B 781 4)California <br /> CNVM <br /> Sur <br /> veY Form - Page 1 I 1 1140826 <br /> (No <br /> w.04104) <br /> Integrated Wastst Management <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` fG z ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � w 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By 'Inspector <br /> Physical Address <br /> Li Q i <br /> Street <br /> Inspection Date <br /> city - � State L Z!P Code Time In Time Out <br /> Business Rep Title AM 0 AM <br /> O PM � � 3 � QPM <br /> Operational Status Tire Type Business Role. Storage Type <br /> The Count(Whole/PTE) t (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> r --r-- ---- O <br /> Latitude i , I . I O Closed O Altered <br /> GPS W Q Hauler 0 indoor <br /> F <br /> O Inactive Truck <br /> Longitude - TT <br /> I 0 Planned 0 OTR 0 End Use Q.Container <br /> Business Type (Fill all that apply) . <br /> 0 New Tire Dealer 0 Auto Repair ®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 I <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and.End-Use FacilityENFORCEMENTS!AT1US <br /> [y A HAULINGANDMANIFEST REQUIREMENTSf"" "¢ °' <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. ComplianceADeadliiie <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days. ,: (Required forNOV or <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ;0 Referreii.`/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 in+Co�mpliance, No Violattiins <br /> 0 0 Other: § <br /> i <br /> Comments <br /> Inspection Form Included: 0 <br /> CommentsIncluded: ®— � - �'// <br /> Business Rep's Signat re. •Phone Number nspectors Sign re Phone Number •� <br /> 62081. <br /> INSTRUCTIONS ON BACK ICorr"eco correct:', Cly EjX AjM P Lj 1112. 3 <br /> White Copy:CI Yellow Copy:Operator Pink Copy:LEA ® ■ <br />