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IN s~n-.spec_t-i_o.-.n Rep <br /> ort Number umber <br /> eofCalfornia <br /> CIW /04) Survey Form Page1 V - AV 4 53 <br /> L _ <br /> 'Waste Tire Su_ y & Inspection Deport <br /> Californialntegrated Waste Management Board <br /> ,I - <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one <br /> Site Suffix: r 0 —7 - 0Routine QRe-inspection <br /> Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP 0 CIWMB 0 Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical 1Address <br /> Street I <br /> Inspection Date Lo <br /> J <br /> 1212 b— -s <br /> City State Zlp Code Time In Time Out _ <br /> Business Rep Title > } AM 0 AM <br /> / / �' lJ 0 P � • � 0PM <br /> Operational Status / ( r �' Business RoleyPt <br /> (Fill one only) FPI, (Fill all that apply) tW (� tI <br /> k��m Q Active ������ �� (D Generator <br /> O Closed <br /> p8_ Latitude O Hauler 0 Inactive <br /> r Arri <br /> "p 't <br /> 0 Planned <br /> Longitude — % M Q End-Use <br /> g r� � .dt" d°�"`f" <br /> r <br /> 0 New Tire Dealer 0 Auto Repair O Trucking Fleet 0 Government O Retreader (�p Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer Q Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Q Other e <br /> J <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Notice Of Violation Q Extension <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline t�� 5 '"t� rrr <br /> O O PRC§42956-Registration/Decal in Vehcle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 14 CCR 18459.2.1 -Submittal of Manifest Forms and Tire Tri Logs within 90 days (Requ/red forNOV orEX7) <br /> 0 § P 9 Y i... <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 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 <br /> y <br /> O Other: <br /> § yLmg.y, <br /> Comments <br /> '.;rel s p; <br /> o <br /> Inspection Form Included: 0 ' <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />