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: <br /> Waste N _n--,.s, pecti_o._ n Re-p-ort NumberWaste Tire Su!�y & Inspection Report <br /> State of California <br /> CIWMB 181 ei <br /> California Integrated Management Board { J A 4 V 'ka Survey Form - Page 1 <br /> - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> �' �'le...� lw 3 a,, � «..x � ., ,,ti, al e�„»� ro ^�".. �,,� �� ,,�I"� �C� 4t�1tS s �� �'F rr a r'r f��"� xz, x ✓GY �,., a'ti'�i^rb r� �,�'�'. <br /> TPID- ,_� i Inspection Type (Fill on <br /> Site Suffix: # ( � l I ! 0Routine Q Re-inspection O Referral O Observation <br /> If Refe <br /> Local rral,choose referral type(Fill one) <br /> Identifier: �- <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Other <br /> Business or Facility Name Inspected By Inspector <br /> Ph teal Address <br /> `�-7 - i - -- <br /> Street ` Inspection Date <br /> CityState ZIP Code Time In _ Time Out <br /> Business Rep Title 1 O AM m m O AM <br /> �.. L 0 PM LTJ 0 PM <br /> ✓� �-��” u Operational Status Business Role Storage Type <br /> �� ih xrFill all that a Fill all that a <br /> (Fill one only) ( t)Iti tp )y) ( apply) ( apply) <br /> dr Q Active O' ' erfr Q Generator Outdoor <br /> Iv ---.0 O Closed Q AItCdr <br /> Latitude <br /> GPS O Hauler O_ Indoor <br /> m - I <br /> O O Inactive O Truck <br /> Longitude0 Planned 0 r k♦ O End-Use Q Container <br /> OTR i�~,dr�� <br /> � Ines �' it 'aPplY� <br /> New Tire Dealer Q Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> D Used Tire Dealer O Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder O Other <br /> Part B 'Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> j V A k,' O Notice Of Violation Q Extension <br /> AULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O j O ! PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§'18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / 7 <br /> O O 14 CCR§ 18459.1 (a)(b)(c)-Tire PrograM ID Number from CIWMB <br /> O O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV,,EXT) <br /> O O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§ 18462-Manifest Sys-tem Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O O Other: § -- - _ _. ------- -- <br /> Comments!- <br /> -- - <br /> Inspection Form Included: 01 r' ,alw/,v md/'xx"A` / dmS.t;iyv,�F, +;m"": / ..ykv°Y �llk"rkre'm„IMu`ktgrY}vom'i?; r�!Wrn;X� <br /> Comments Included: Q _ <br /> Business Rep'sSignature Phone Number In Signature Phone Number, <br /> INSTRUCTIONS ON BACK Correct:O Incorrect: �f a ::� r, ��"��=” I� t. 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />