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Waste Tire Sury & Inspection Report Inspection Report Number ■ <br /> sa <br /> State <br /> via CIWMB <br /> f 81(New Survey Form - Page 1 - 3 <br /> CIWMB 1S1(New 04/04) <br /> California Integrated Waste Management Board - <br /> Part A Survey BLUE OR BLACK INK PEN <br /> zeta <br /> �i Det�il� <br /> TPID- _ -� / Inspection Type (Fill one) <br /> I Site Suffix: ` f ® 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 By Inspector <br /> I / <br /> Physical Address <br /> Street /_ <br /> Inspection Date <br /> �y State IPS Time In _ Time Out <br /> Business RepTitle MC <br /> 1 r C O PM ( `' O AM PM <br /> „u Operational Status Tire Type I Business Role Storage Type <br /> ' n (Fill one only) (Fill all that apply); (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ' (- <br /> ® Active Q Passenger (V Generator Q Outdoor <br /> GPS Latitude m , �!10 OClosed Q Alte <br /> C . u' <br /> l <br /> Q Hauler Q Indoor <br /> �� Q Inactive 0:T-7-77 7__T__T 70 <br /> Longitude — Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <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 HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts With Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-RegistratioN,Decal in Vehicle <br /> OO 14 CCR§ 18459 -fiesponsl le Entities Complying with Manifesting Requirements Date T / m / M <br /> Q O 14 CCR§18459.1 (a)(b)(c) Tire Program ID Number from CIWMB <br /> Q O 14 CCR§ 18459.2.1 Submit. I of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§ 18459.3-Retentionf Manifest Forms and Tire Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Ma ifest stem Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Ma nife t Sy m Requirements for Waste Tire End-Use Facilities <br /> 18462-Manifes' q m S st Requirements for Tire Dealers or Waste Tire Generators <br /> O O 14 CCR§ y <br /> Q In Compliance No Violatiops <br /> O O Other: § .a- <br /> Comments '? r' <br /> - (( 1 -7 t <br /> 4f. <br /> ,•„r r,. ,2, ., rr�� ,. t - <br /> Inspection Form Included <br /> Y�i.e r,f"au .'�^"�' s,�„»,' 6 sa r ,ti��,•,i�1�� �.%��°��'„'�:r s7"r✓3. �, ,.r�. "„�"� �'f`1` ,�,"F � ' ��� <br /> Comments Included: Q <br /> Business Rep's Rep's Signature Phone Number Inspector`s Signature „� „a ; <br /> ® i 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X V +�'1A a” 1, I. L L <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� ■ <br /> A <br />