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JML m it- n� <br /> r , <br /> Waste Tire Suft & Inspection Report4ospection Report Number <br /> „�, State of California Survey Form - Page 1 t � - � 1 <br /> CIWMB 181(New nage <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile RILInspection Details <br /> TPID- Inspection Type (Fill one) <br /> 3 Site Suffix: I ' -7 LoLl Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> z -4� 0CHP 0 CIWMB QCom taint QEducational Visit QOther <br /> Business or Facility Name r <br /> Inspected By Inspector <br /> Physical Address <br /> Street Inspection Date <br /> City State ZIP Code Time In Time Out - <br /> Business Rep Title m O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/l (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � <br /> (S Active 0 Passenger 0 Generator 0 Outdoor <br /> k 7E <br /> F � 0 Closed 0 Altered <br /> GPS Latitude m d <br /> 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station @ Hauler 0 Agriculture 0 Shredder 0 Other <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 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / FTI <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Ij <br /> TOF- <br /> - ---- - - " <br /> Inspection Form Included: 0 <br /> - <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspectors SignaturePhone Number <br /> . . <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X X A m P L 1 2 3 62041 <br /> Whl T <br /> Copy:CIWMB Yellow Copy:Operator Pink Copy:'LEA <br />