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Y� <br /> giiffl Waste Tire Sut,-,:y & Inspection Report Inspection Report Number ■ <br /> GgratCalifornia <br /> e 1aasteManagel Survey Form - Page 1 1 3 - 1 0 1 0 8 5 0 <br /> California integrated Waste Management Board <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> I TPID i ` - Inspection Type (Fill one) <br /> site Suffix: l <br /> '® Routine QRe-ins Re-inspection <br /> Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: _ r <br /> _. _ � - � _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector r // <br /> Physical Address <br /> Inspection Date <br /> i r <br /> --_ -- - Time In Time Out _ <br /> - <br /> Business Rep Title iQ AM i Q AM <br /> O PM <br /> Operational Status Business Role <br /> Count(Whol (Fill one only) (Fill all that apply) <br /> .: ) <br /> Q Active Q Generator <br /> GPS Latitude O ® Closed <br /> Q Hauler <br /> Q Inactive <br /> Longitude - <br /> Q Planned Q End-Use <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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/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 <br /> Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection F' - <br /> Comments Included Q <br /> Business Rep's Signature Phone Number Inspector's.Signafuce Ptrone Number <br /> - _— -- 62081 <br /> ■ INSTRUCTIONS ON BACK Correct:0 Incorrect: X E,X1A MjPjLTEj 111 2 3 © ■ <br /> W hits -:y GW ME Yellow Copy:Operator Pink Copy:LEA <br />