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Waste Tire Sur, _ ;y & Inspection Report .Inspection Report Number <br /> rr" <br /> CIWMBB191(New 04/04)stateCalifornia Survey Form - Page 1 18 - 1 0 1 3635, <br /> - rr• <br /> California Integnated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Surve <br /> TPID- _ _7 I Inspection Type (Fill one) <br /> Site Suffix: I �� j / �i / n /- 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. `-!Lr,+ t fh[t-<- � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or FaciliName .T— <br /> t1' Inspected By Inspector <br /> Physical Address <br /> Street- . _ Inspection Date E / `U <br /> -- State ZIP Code Time In Time Out <br /> Business Rep Title �., / / O PM m : ®/ 0 AM <br /> !� 0 PM <br /> Operational Status Business Role <br /> Tire Count (Whole/P J (Fill one only) (Fill all that apply) <br /> ©Active ® Generator <br /> D O Closed <br /> Latitude <br /> ('jPs Q Hauler <br /> ' o Q Inactive <br /> Longitude - Q Planned Q End-Use <br /> Q New Tire Dealer Q Auto Repair O 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 /> `a <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V1 A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 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 / 7 / El <br /> �1 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 /> 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 114 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 /> l Q Q 1 Other. § <br /> t - - <br /> ( Comments <br /> t <br /> Comments Included: Q <br /> Business Rep's Signature <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X A 111 1 , 2 3 62081© ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />