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= E Waste Tire Sur . I & Inspection Report spection Report Number <br /> State CIWMB California I 1 - 114 0 8 8 7 <br /> grated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLU_ E OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: •+Z `� G '0 Routine 0 Re-inspection 0 Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �i O CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Nam Inspected By Inspector <br /> Physic Address 3 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM / 0 AM <br /> .Z ® PM 0 / <br /> ! 0 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 /> f 02 •Active 0 Passenger ®Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS LatitudeO Hauler ®Indoor <br /> O Q Inactive ®Truck <br /> Longitude – O Planned ® OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) w <br /> 0 New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body O Car Dealer 0 Collection O Crumb Rubber <br /> 0 Service Station 0 Hauler O Agriculture 0 Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle – <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / W <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> 0 O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® In Compliance - No Violations <br /> Q 1 0 Other: § <br /> Comments <br /> Inspection Form Included: Q' Sy <br /> Comments Included: ® — <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> IN ON BACK Correct: Incorrect: X , \ `, P � p <br /> 62081 <br /> I. <br /> White Copy.CIWMB Yellow Copy:Operator Pink py: <br />