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- Waste Tire S e Y p& Ins ection Re OInspection-port Number <br /> p <br /> _ -- _. <br /> State of California <br /> arCIWMB 181(New <br /> Manage) Survey Form - Page 1 - 1 0 2 5 8 5 <br /> Californiania Integrated Waste Management Board .-. _... I <br /> Part A- Survey BLUE OR BLACK INK_ PEN <br /> inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 � ® Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. 0 CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name 1 t f <br /> i Inspected By Inspector <br /> - <br /> Physical <br /> Address � - <br /> T-1 <br /> Street / 1 <br /> l Inspection Date <br /> City V State IZIP Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> �< O PM 0 PM <br /> ED : I <br /> ' _ <br /> 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 /> 9Mi(r�r <br /> Active 0 Passenger 'j Q Generator a Outdoor <br /> D 0 Closed 0 Altered <br /> GPS Latitude ` "�„°� Q Hauler 0 Indoor <br /> �70 O Inactive 0 Truck <br /> Longitude -� � � O Planned Q OTR 0 End-Use 0 Container <br /> Busin _,-'type (Fill all that appy) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet Q Government O Retreader 0 Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer O Auto Body 0 Car Dealer O Collection O Crumb Rubber <br /> 0 Service Station O Hauler O Agriculture 0 Shredder 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 <br /> O Notice Of Violation " Q Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 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 O In Compliance - No Violations <br /> Q Q Other: § <br /> Comments r. <br /> `i -T' y'/i.t r'l /:�� - f/;y 1llF.. !i !r, + ..-.r r- ✓ rt -t � l �- <br /> l— ! - <br /> 1T`i Jzk,t <br /> - 1 <br /> Inspection Form Included: O <br /> Comments Included: 0 - <br /> Business Rep's Signature Phane NumLer inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 1,- 01 <br /> .. ._nWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />