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Waste Tire Sy & inspection Repor �.Inspection Report Number ■ <br /> 9i6 State of California s. <br /> CIWIVIB Waste <br /> eManag) Survey Form - Page 1 6 - 1 0 .1 3 0." 71 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE'OR-BLACK INK PEN. <br /> r ;Profile Inspection Details <br /> TPID- _ Inspection Type (Fill one) f ; <br /> Site Suffix: 0 0 � o Routine o Re-inspection Q Referral <br /> Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: ` <br /> (I{A o( - .- v( Q CHP Q CIWMB Q Complaint Q Educational Visit"Q Other <br /> Business or Facility Name Inspected By, — Inspector <br /> Physical Address <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> /— 1 mm0PM m � m DPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Whole/PTE <br /> Tire Count <br /> ( ) ❑ f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator o:Outdoor <br /> ® Q Closed Q Altered <br /> GPS Latitude m 0 Hauler Q: Indoor <br /> O Q Inactive o Truck <br /> Longitude — FF] I 1 Q Planned Q OTR o End-Use o 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station C) Hauler Q Agriculture Q Shredder Q Other - I -- <br /> Part B= Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> �Vj A HAULING AND MANIFEST REQUIREMENTS 9 Notice Of Violation Q Extension <br /> o -.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 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Dater mt � <br /> Q 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB �c <br />.__-_0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and.Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years _ <br /> 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q o 14 CCR§18461 -Manifest System Requirements for Waste Tire End-.Use Facilities <br /> Q o 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators • In Compliance - No Violations <br /> Q 1 Q 1 Other: <br /> Comments <br /> V <br /> 10 t_ 1/1 l r t t <br /> Inspection Form Included l5 t ' <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector"s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X t � � Ri lls .L t .2 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® �`■ <br />