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■ "' rlOy & Inspection Report ` Inspection Report Number <br /> Waste Tireu <br />• 8888- State of California <br /> f BRia CWMB181 <br /> New04104) Survey Form - Page 1 9 -*10-0 6 3 $..3 <br /> ,�Mfornia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- FTT <br /> 71m Inspection Type (Fill one) <br /> Site Suffix: E, <br />� Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �t � /�� Q CHP Q CIWMB Q Complaint (E) Educational Visit Q Other <br /> Business or Facility Name f Inspected By Inspector <br /> Physical Address <br /> � <br /> Ph <br /> Street <br /> n Inspection Date <br /> / <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title @ AM O AM <br /> l � • �0PM m • m QPM <br /> m�(WholelPTE Operational Status Tire Type Business Role Storage Type <br /> Tire Count ) ❑f l_L_J�J f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q;Outdoor <br /> D I Q;Altered Latitude m • Closed Q Hauler Q: Indoor <br /> GPS <br /> 1 Q Inactive Q'Truck <br /> Longitude - TTI Q Planned Q OTR Q End Use Q Container <br /> 8 siness 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 12 /&�GY <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 - - Q Notice Of Violation Q Extension <br /> 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 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 /> 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 /> Q Q Other: § <br /> Comments <br /> to ,C-; 1fr 7'tr <br /> �, �- - , `, <br /> Inspection Form Included r <br /> Comments Included: G N f f / t <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number r <br /> 62081; <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: , A .�P f' <br /> � <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />