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nspection Report Number <br /> Waste Tire Sur- ..y & Inspection Report <br /> State of California /'1 <br /> CWMB Waste <br /> Survey Form - Page 1 1 b - 1 0 2 5 0 2 0 <br /> California Integrated 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: 7 I - (9 Routine Q Re-inspection Q Referral Q Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: �� � 1, > Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> _ Inspection Date <br /> State ZIP Code Time In Time Out <br /> Business Rep Title // O AM I O AM <br /> O PM - -1�1 L O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m • Q Hauler Q Indoor <br /> TI -- O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 ®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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 Q In Compliance - No Violations <br /> O 0 Other: § - - -- — <br /> Comments r ? �_ ,✓. ,,,-�..- �-, _ � (" + -? � � � -� /� <br /> V <br /> Inspection Form Included: Q <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number Inspector's Simnature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X Ii 62081 <br /> kd X,N a�, � L E Z � 3 <br /> White Copy,!CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> I <br /> f <br />