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Waste Tire SL' - ey & Inspection Repor" Inspection Report Number <br /> State of California P <br /> California <br /> CIWMB181 <br /> Waste <br /> eManag) Survey Form - Page 1 [J z) 1 0 7 9 8 1 9 <br /> California Integrated Waste Management Board --------- --------- <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> TPID- �) <br /> Inspection Type (Fill one) <br /> f Site Suffix: 1 / k- 1JT f ! EE 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local - If Referral,choose referral type(Fill one <br /> Identifier:,J J „ t , ; ! t 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name L' <br /> Inspected By Inspector <br /> 4 -- <br /> �.-' & <br /> Physical Address/ i ! i 7 :' ' �m <br /> I i / �,J �� r- <br /> i I <br /> Street <br /> Inspection Date <br /> Time In l Time Out <br /> City State ZIP Code <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> --- - - ---- Operational Status 1�ire`Type Business Role N&zIge Type { <br /> Tire Count (Whole/PT (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> Is Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude <br /> O 0 Closed 0 Altered <br /> m <br /> 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 1 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) _ - <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> (Z) Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 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 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 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I 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 /> i <br /> Inspection Form Included: 0 <br /> Comments Included: 0, -. �-----^-�- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X E Xf A P 62081 U 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />