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■ = Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State <br /> WMBCalifornia Survey Form - Page 1 ( 4 - 0 1 3 9 l <br /> CIW ted W (tJeManage) Y <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN__ <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> Inspection Type (Fill one) <br /> Site suffix: - _ 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalC^�� If Referral,choose referral type(Fill one) <br /> Identifier: GL/L �QQjy _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (� <br /> � Inspected By Inspector <br /> /r^u!,i�0 <br /> Physical Address <br /> Inspection Date <br /> C O Time In Time Out <br /> Business <br /> /Rep Title / / AM / ®AM <br /> O PM O PM <br /> -- Operational Status; Tire Type Business Role Storage Type <br /> Tire Count (WholelPTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger Generator <br /> 9 � 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULNG AND MANIFEST REQUIREMENTS, <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires - O Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-RegistrationlDecal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / LL] <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 0 Referred l 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 In Compliance'- No Violations <br /> Q Q Other: § -- -_ <br /> Comments j'&r- <br /> Inspection Form Included: Q <br /> Comments Included: Q - ---- ��t5 `�����' ! ✓'`�����""� e Y�� �1� <br /> siness Rep's_Signature - Phone Number Inspector's Signature Phone Number-1 <br /> INSTRUCTIONS N BACK �.�.,. a,.r Pi 62081 <br /> ■ ,e. © ■ <br /> While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0633304. 0076 <br />