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Waste Tires y & Inspection Repo 417P <br /> ection Report Number <br /> State of California <br /> forniai CIWMB 181(New <br /> Manage) Survey Form - Page 1 -� $ Q . <br /> g gement Board _.___..._ _._____ <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> 'Business�Profilee ra e a � <br /> — Waste Management <br /> Inspection Details <br /> } TPID- I r �` Inspection Type (Fill one) <br /> Site Suffix. t \ Routine Re-inspection Q Q p Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> P y Inspector <br /> Physical Address <br /> Street <br /> .11 Inspection Date Ej�� <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title —� _ Q AM I <br /> IT—0 PM Q AM <br /> �_.._ ...__E O PM <br /> Operational Status Tire Type Business Role <br /> t <br /> Tire Count(Whole/PTE)' (Fill one only) (Fill all that apply) (Fill all that apply) <br /> s ,� <br /> E) Active Q Passenger Q Generator <br /> Latitude C Q Closed Q Altered <br /> GPS <br /> Q Hauler <br /> i <br /> �) <br /> Q Inactive Q Truck <br /> Q End-Use <br /> Longitude — C nse <br /> Q Planned Q OTR <br /> 'BUSIneSS <br /> s <br /> s. ,,,!.:_S <br /> Q New Tire Dealer (S Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> _ r <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A <br /> HAULING AND MANIFEST REQUIREMENTStio - --- <br /> Q Q I,PRC§42951 -Waste Tire Hauler Reg istran a- -_nd-Transport——of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle / <br /> Q 1 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> pQ <br /> In Compliance No Violations <br /> Q Q Other: § <br /> - <br /> Comments <br /> i <br /> Inspection Form Included: Q', <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK CorrectV Incorrect: X 1�1 � i:_ � a. �W�' �� �iW i LL - <br /> 62081 <br /> - © ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />