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Waste Tire Su. y & Inspection Repor�spection Report Number <br /> Gti�7 State of California . <br /> CIWMB 181( e ) Survey Form - Pagel 1 $ 1 0 1 3 L 3 ] <br /> California Integrated WasttManage <br /> Waste Management Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I - C (3 Routine 0 Re-inspection Q Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier:., Com, �.. --� O CHP O CIWMB Q Complaint O Educational Visit O Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address / <br /> C,q, <br /> Street <br /> Inspection Date <br /> CrTy `— State ZIP Code Time In Time Out <br /> Business Rep Title L O AM O AM <br />_ r, � • 0 P OPNI <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PT (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> O Active 0 Passenger Q Generator 0 Outdoor <br /> F7 <br /> D (3 Closed 0 Altered <br /> GPS Latitude W . Q Hauler Indoor <br /> 10 Q Inactive O Truck <br /> Longitude - Q Planned 0 OTR O End-Use ontainer <br /> RF <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government O Retreader O Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body O Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q 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 /> Notice Of Violation 0 Extension <br /> Q O 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 <br /> M / M / m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <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 O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance No Violations <br /> O O Other: § <br /> Comments <br /> Inspection Form Included 0; <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ,� <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � � it X l A ?AIF L t 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />