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Waste Tire S & Ins Inspection Re o <br /> V p Inspection Report Number ■ <br /> ■ �u33uxi' State of California ! r �.. ......,___. .._......._... _ .--..... <br /> CIWMB 1 teMana a Survey Form - Page 1 f- 3 - 1006650 ,. <br /> California Integrated Waste Management Board _ <br /> Part A Survey BLUE OR BLACK INK PEN <br /> � <br /> t"k <br /> 0w. , <br /> f TPID- 1 Inspection Type (Fill one) <br />+ Site Suffix: �� � <br /> _ I1 I' @ Routine Q Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> Physical Address <br /> street _ <br /> Inspection Date <br /> I-A <br /> / State ZIP Code Time In Time Out <br /> Business Rep Titlej � AM0 AM <br /> L �1 ��d PM l (. 0PM <br /> Operational Status Tire Type Bess Role Storage Type <br /> 1�9Ceo0.19I "( t� IlT �'" (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude o O Closed 0 Altered <br /> CIPS I 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude -�� 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 Goverry_. t 0Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection b 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 ENObRCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> ---- - 0 NoticeOff Viof�t;on 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 y_• <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 0 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 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 <br /> 0 In Compliance - No Violations <br /> 0 0 Other: § --._ <br /> Comments <br /> r <br /> Inspection Form Included; 0 <br /> Comments included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: +, <br /> ■ L ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> f <br />