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Inspection Re oto m <br /> Nuber <br /> Waste Tire Sey & Inspection Reportpp <br /> ■ ,nEu�Z. State of California <br /> ern' CIWMB 181( e ) Survey Form - Page 1 .1 0 .A O 6 6 3 1California Integrated WasttManagement <br /> Waste Management Board - � -- - -- <br /> Part A Survey BLUE OR BLACK INK PEN <br /> Profile Inspection',Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix ' F j r t/ , Routine Q Re inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: i Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L-' — <br /> Inspected By Inspector <br /> Physical Address ✓' r, l r tLd <� t'1 P �. lcr q <br /> �•l t �.. <br /> Street <br /> r _ _ Inspection Date <br /> 1�;f f:. ►� J "f �.J{i 110 I Time In Time Out l <br /> City State ZIP Code <br /> Business Rep Title O AM AM <br /> PM O PM <br /> E --- <br /> J <br /> .y:fr, i• l r� .•\ ;f�: ;t rte' _('•- • I ._ �. ....^ <br /> Operational Status Tire T Business Role Storage Type <br /> (Fill one only) (Fill ali �a� (Fill all that apply) (Fill all that apply):... . <br /> Active Q P ���'� (2 Generator Q Outdoor <br /> 77Latitude O Q Closed Q Alt # ir <br /> GPS J-7 Q Hauler Q Indoor <br /> D Inactive Q Trurk <br /> Q End-Use Q Container <br /> Longitude - Q Planned 00 ., <br /> Business Type (Fill all that.apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retread'( Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubbe <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 AHAULING AID MANIFEST REQUIREMENTS _ _ _ Q Notice Of Violation Q Extension <br /> I <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 /> 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 /> 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 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 �•t",' t., <br /> �4 <br /> r ��t (i > <br /> Inspection Form Included: Q, <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:, Incorrect: X t .p A <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />