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- <br /> ;i<,� Waste Tire SAW & Inspection Re Or nspection Report Number <br /> II a'dd. State of California p <br /> CIWMB grated Waste <br /> eManag) Survey Form - Page 1 ! Z 3 1 Al <br /> California Integrated Waste Management Board ,, ' <br /> Part A- Survev BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> -} $ite Suffix: — c l <br /> 7 (J)Routine 0 Re-inspection 0 Referral 0 Observation <br /> entifie <br /> Localin _ If Referral,choose referral type(Fill one) <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Bus ess or Facility Name — - - - <br /> Inspected By Inspector <br /> -- Physical Address <br /> A <br /> i <br /> -3� <br /> Street 2`�-� <br /> f5 LL- 1 _ %� Inspection Date [ous- <br /> Uty <br /> �-, State77PZIPS Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> Q PM PM <br /> s r " d 4 a� W` �Operational Status Tire Type Business Role Storage Type <br /> TheCount(Whole/PTE) (Fill one only) (Fill all that apply)': (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> E== <br /> C 0 Closed 0 Altered <br /> Latitude ED • <br /> 0 <br /> O 0 Inactive 0 Truck Hauler 0 indoor <br /> Longitude _ <br /> �- �� • � � � � � 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that aPP1Y)' <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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 /> D D14 CCR§ 18459.1 a b c -Tire Program ID Number from CIWMB Ki <br /> m m m <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 0 Other: § <br /> 0 In Compliance - No Violations <br /> Comments <br /> _ ..... .G >. <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: v - 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />