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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Stateof California <br /> CIWMB 191( e ) Survey Form - Page 1 1 7 - 1 0 2 5 81 1 <br /> California Integrated WasttManage <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- fl 1 Inspection Type (Fill one) <br /> Site Suffix: t7 3 ` 0 Routine ® 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 l <br /> C, 5 Inspection Date <br /> / Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Operational Status' Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> C 0 Closed 0 Altered <br /> i GPS Latitude 0 Hauler 0 Indoor <br /> O 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 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 <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility I.ENFORCEMENT STATUS <br /> A. `HAULING AND MANIFEST REQUIREMENT$ 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 <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 /> O 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 RsfArred 1 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 0 ;Other: § In Com lianas - No Violations <br /> Q P . . I, <br /> Comments <br /> Inspection Form Included: 01J <br /> Comments Included:0, ���`�o <br /> 1 Business Rep's Signature Phone Numbers In pector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct *` 4ncorr >3t,. ( v L� � tI � i 11 2�-3I 62081 <br /> _ <br /> White Copy:CIWMB Yellow Copy:opy:Operator Pink Copy:LEA <br />