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Waste Tire SLey & Inspection Repo Inspection Report Number <br /> 6R�81 State of California /� J''� /''� 'r` I� l <br /> California Integrated13,Waste 81 eManagement Board Survey Form - Page 1 1 L - 1 V V 6 V L 6_ <br /> Part A- Survey BLUE OR BLACK INK PEN <br />} TPID- L/ m Inspection Type (Fill one) <br /> Site <br /> Site Suffix: � I I � I I�i/ Q Routine Q Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date <br /> City State ZIP Code I Time In Time Out <br /> A <br /> Business Rep \. Title 0 AM 0 AM <br /> � QPM O PM <br /> r -_... <br /> .- ... <br /> t I Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PT. zl T- <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0Altered <br /> m <br /> GP$ Latitude 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 0 Hauler 0 Agriculture 0 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 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 / m <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 O <br /> 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments I f <br /> Inspection Form Included: 01 _ <br /> Comments Included <br /> Business Rep's Signature Phone Number Inspector"s. ature Ptt ,�ltrnper <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X A�, l: _XTA M p I 62081 <br /> --- _ - -- <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />