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�= Waste Tire Su, & inspection Re O inspeefbn Report Number <br /> W y a a - _State of California StWM8181fornia 104) - Survey Form - Page "�-: 1 4 10 7 3 4 A 5 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile lirispection Details . <br /> - EM <br /> Inspection Type (Fill one) <br /> Site <br /> Site Suffix: � � O � � � g Q.Routine Q Re-inspection Q Referral Q Observation <br /> TPIDLocal — If Refereal;choose refeffahtype(Fill one) - <br /> Identifier: Q CHP Q GIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> I y 9 < <br /> Street <br /> Inspection Date <br /> City State Z P-T Code Time InTime Out <br /> Business Rep Title O AM Q AM <br /> / /r <br /> (D PM mem 0PM <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 /> 9 f f (DActive Q Passenger Q Generator Q Outdoor <br /> TTIO <br /> Q Closed Q Altered <br /> GPS Latitude m • ,"Hauler Q Indoor <br /> p Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR (3 End-Use Q Container <br /> ------- -- <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 Q Hauler Q Agriculture Q Shredder Q Other I I <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 /> 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 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive 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§1846 Manifest System Requirements for Waste Tire End-Use Facilities <br /> equ <br /> 14 CCR§1846 t Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q ) Q In Compliance - No Violations <br /> Q Q Other: § \ <br /> Comments << 3sat Vj, Coe[ <br /> Inspection Form Included: Q <br /> Comments Included ... .... _r ... ---------....... - <br /> Q Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _- - ------ 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: V� E .14 MP �. ] , 3 <br /> ■, White Copy:CIWMB -Yellow Copy:Operator' Pink Copy:LEA <br />