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-am JIM - <br /> Waste Tire SAW & Inspection Repor nspectionReport Number <br /> K- iiaG State of California . <br /> California Inegrat d,81 Was eeManagement Board Survey Form - Page 1 . I. 1 f 10 <br /> Ai{ 4 i/ }/'�'�1 V -T <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- _TTL Inspection Type (Fill one) <br /> Site Suffix: I Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> •. <br /> Identifier. 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> �q Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Street - <br /> Inspection Date -2i <br /> City State ZIP Cod& Time In Time Out <br /> Business Rep Title n O AM O AM <br /> / W � 0 PM m 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/P <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude <br /> 0 Closed 0 Altered <br /> m <br /> 0 Hauler 0 Indoor <br /> D (b Inactive 0 Truck <br /> 0 End-Use Longitude — 0 Planned 0 OTR <br /> �� Container <br /> L Bushes!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 /> 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 (a Other r/� �- <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 Tirc Hauler Registration and T,,ansport 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 /> 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 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 /> Inspection omrrr ed: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ._._ � <br /> INSTRUCTIONS ON BACK Correct: X Incorrect: � f_-_XI�? ,�,4 P L E 1112 3 62081 <br /> White Copy.CIWr,IB Y'JIoU c n OIs -1tor Pink Copy:LEA <br />