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"t> Waste Tire Suft & Inspection Reportftspection Report Number <br /> `�» State 811(New04/04) Survey Form - Page 1 1 8 - 10 13 4 <br /> California Integrated Waste Management Board <br /> 0 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> ITPID- <br /> 71 qj A T _t/ 1 Inspection Type (Fill one) <br /> Site Suffix: / ! 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ^ . .-•^-- If Referral,choose referral type(Fill one) <br /> Identifier: - L ,0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name r-- <br /> Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> State ZIP Code Time In Time Out <br /> Business Rep Title 0AM m 0 AM <br /> � • m0PM • � 0PM <br /> h. Operational Status Tire Type J <br /> Business Role Storage Typ <br /> Tire Count (Whole/PTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that app <br /> 2101 (�)Active 0 Passenger Q,Generator 0 Outdoor <br /> 701 <br /> 0 Closed D Altered <br /> GPS Latitude 0 Hauler Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned OTR End Use ontainer <br /> l that appl . <br /> -0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> @ 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 I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - — ------- 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 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/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 ' <br /> J"11 <br /> f <br /> ttSpeCtltSfl l7f'm'` nC ll ed: 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: X 0'iml P I L I e 1 2 i -'. <br /> WhitB Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0 <br /> 1 <br />