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Waste Tire Suoy & Inspection Repor Inspection Report Number ■ <br /> I - _ <br /> Gid$ State of California 9 <br /> CIWMIS e ) <br /> California Integrated Waste Management Board SurveyForm - Page 1 <br /> Part A Surve BLUE OR BLACK INK PEN <br /> .,. .,.-b <br /> Ins <br /> .. <br /> TPID- � _-- Inspection Type (Fill one) <br /> w . .. <br /> Site Suffix: Ef� 0,Routine Q Re-inspection 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 Inspected B <br /> VTom _ P y Inspector <br /> Physical Address <br /> I <br /> 7(/") <br /> Street <br /> Inspection Date <br /> City i State_ZIP Cade Time In Time Out <br /> Business Rep Title ff0 AM 0 AM <br /> . I0 PM M <br /> ' m 0 P <br /> Operational Status Business Role <br /> (Fill one only) �� i �', (Fill all that apply) <br /> ' 5 <br /> Active % ✓x Q Generator <br /> GPS Latitude m . Q Closedi <br /> Q Hauler <br /> E=10 Q Inactive <br /> 1� ,r <br /> Longitude — Q Q End Use <br /> Planned i <br /> ft '" <br /> ; �,ro�^✓ria s r w � * r to r'�rr� : r !✓ 1" <br /> Y,. �,;• _,. ""Imw � rW; <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> """I <br /> 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 /> VV A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q <br /> Extension <br /> Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> :" <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 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 orEXT) <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 ,;{ 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q (Other: <br /> Comments f •� r <br /> r <br /> IN <br /> vi "mam -z" <br /> 1 fit,. r f <br /> � `� '��" 'r�� f� �� ✓ Slll 3 � � v��r,y�y n r �, rr»„s � � r;w+ yre�� �,: <br /> - __a.�a,* �d tom, ��w�'���`'¢��"':,�..� - Sl.�r1� , 1 i_xis„' u :" ,�,`�.��::_n +�" ..,.�.•y x 4.f,. .. � +�� :fo-��4�i"ic' ��'''* a%.i.� '�' <br /> INSTRUCTIONS ON BACK C rrect Incorrect '` �,� M ; _I_[ n y 62081 <br /> ■ White Copy:CIWMB Yellow Cop�tYOperator Pink Copy:LEA © ■ <br /> F <br />