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Waste Tire ey & Inspection Rep&*, Inspection Report Number <br /> ■ '.C'' W:.. State of California ! h h <br /> ern � CIWMB1811(New Mana a) Survey Form - Page 1 11 1086910 <br /> California Integrated Waste Management Board .. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profilel - <br /> Site Suffix -� Inspection Details <br /> TPID- ' } Inspection Type (Fill one) <br /> `J <br /> # - (0) Routine Q Re-inspection Q Referral Q Observation <br /> Local ®' If Referral,choose referral type(Fill one) <br /> Identifier: ��{ n �) {1 1. ( 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> t <br /> Business or Fac(>� ility Name Inspected By Inspector <br /> , <br /> i <br /> Physical Addr ss <br /> L� <br /> Strr,et <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM AM <br /> ^`u 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 /> Active 0 Passenger Generator Outdoor <br /> 7i0 <br /> 0 Closed 0 Altered <br /> GPS Latitude t � , 0 Hauler 0 Indoor <br /> 0 Inactive 0 Trick <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 ENFORCEMENT STATUS <br /> V A 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 M / m / m 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days - (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive 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 In Compliance - No Violations <br /> 0 0 Other: § <br /> — —._- —----------- — — — <br /> Comments t <br /> i <br /> Inspection Form Included: 0 y <br /> Comments Included. 0 r y / <br /> Business Rep's Signature NumberPhone) Inspector's Sign; re � � Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: [ A Mil1,p � 2 3 62081 <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />