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0 <br />F� Waste Tire Sufty &Inspection Report%lnspection Report Number <br />State of California <br />CIWMB Waste <br />Survey Form - Page 1 ! 8 - 1 0 1 0 7 f 2 - <br />California Integrated Waste Management Board <br />Part A - Survev BLUE OR BLACK INK PEN <br />nspection Details <br />Site Suffix: <br />Local <br />Identifier: <br />Business or Facility Name 'F <br />Physical Address <br />Street <br />CitV <br />Business Rep <br />Tire Count (Whop <br />GPS Latitude <br />Longitude - <br />Business Type (Fill all thi <br />Q New Tire Dealer Q Auto Repair <br />Q Used Tire Dealer Q Auto Body <br />Q Service Station Q Hauler <br />i <br />Inspection Type (Fill one) <br />(a) Routine Q Re -inspection Q Referral <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CIWMB Q Complaint <br />Inspected By <br />C �I ( <br />Q Observation <br />Q Educational Visit Q Other <br />Inspector <br />Inspection Date <br />Title <br />State ZIP Code <br />� Time In Time Out <br />0 AM <br />[Zj: � QAM � � 0PM 'C QPM <br />_j I perational Status Tire Type Business Role Storage Type <br />(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />Q Active Q Passenger Q Generator Q Outdoor <br />U Q Closed Q Altered <br />Q Hauler Q Indoo <br />I QT k <br />O Q nactive ruc <br />Q Planned Q OTR Q End -Use Q Container. <br />Q <br />Q Dismantler Tire Derived Fuel <br />Q Trucking Fleet Q Government Q Retreader <br />Q Car Dealer Q Collection Q Crumb Rubber <br />Q Agriculture Q Shredder ® Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />Other: § L <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred/ CIWMB Enforcement <br />Q In Compliance - No Violations <br />Comments It,r 111'_.i1 cul hl �tt�r"t f �� IVk o{'(�ld�>. ��h✓(� i � /U` ke.4 (lG=,�1Cjktf �lr' C�Ff �+�C <br />c:tt Uc:". c.> i'c1��1 cibtt C7f✓f✓ �t <br />C, ("I" %1` /I(r i�11✓;� t,:)l/S_ <br />If i i1 /:t✓ll'� (-r-r<�}Pf f tZ� �1it l%'L (Y�cj 0 ( .,(f vin -- ✓nic c- Q/i .�(`u 7�Ctfi( /U Ck,�'for <br />/I IFt� <br />spection Form Included: Q <br />Comments Included: Q <br />Business Rep's Signature Phone Number Inspector's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct:* Incorrect: X TA 04 P 62021 � � 12 3 <br />f <br />White Copy: CIWMB Yellow Copy. Operator Pink Copy: LEA <br />