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►:- Waste Tire Su41 * & Inspection Repor ►5pection Report Number <br /> SGS . Stateof CaliforniaCIWMB ( ew 04/04) <br /> Al <br /> Califorria Integrated f W81 aste Management Board Survey Form - Page 1 1 //�L - Aj 5 0 i 3 5 3 9 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- / L _ _ Inspection Type (Fill one) <br /> Site Suffix: I �j 1 `j C <br /> Q Routine Q Re-inspection Q Referral Q Observation <br /> Local �- If Referral,choose referral type(Fill one) <br /> Identifier: _ J L: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Y <br /> 1 Inspected By Inspector <br /> Physical Addr s �� _ ' (� ( I Tc r ;� ti 5 <br /> Street - <br /> r-- Inspection Date <br /> CX <br /> City f State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> m � 0 P 0 P <br /> Operational Status ire Type Business Role orage Type <br /> (Fill one only) Fill all that ap (Fill all that apply) Fill all that apply) <br /> Tire Count (Whole/PTE <br /> ia.Active Passeng *Generator Outdoor <br /> O Q Closed Itered <br /> Latitude m <br /> GPS Q Hauler Indoor <br /> Q Inactive Truck <br /> Longitude - Q Planned Q OTR Q End-Use Container <br /> Business Type (Fill all that ap <br /> _0 <br /> Q New Tire Dealer Q Auto Repair Q 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 HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <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 ® ! 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 <br /> Q In Compliance - No Violations <br /> Q Q (Other: § f <br /> Comments <br /> o <br /> Inspection Form Included: V' <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> +erg 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X is`x d° <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />