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..WY ._ .1L. - - <br /> Waste Tire Sun& & Inspection Report Ispection Report Number <br /> State of California �j ++y <br /> ew 04/04) <br /> California lntegrat dClWMB tWas81 teManagementBoard Survey Form - Page 1 1 4 - 10 13 V V 9 <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- / __ Inspection Type (Fill one) <br /> Site Suffix: I / I � � I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local -- If Referral,choose referral type(Fill one) <br /> Identifier. _ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ` Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> State ZIP Code <br /> Time In Time Out v <br /> Business Rep Title . I JOAM <br /> O PM I I ' I I O PM <br /> Operational Status ire Type <br /> Tire Count (Whole/PTE Business Role torage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) ill all that apply) <br /> 0 Active 0 Passeng„ 0 Generator utdoor <br /> v Closed 0 Altered <br /> GPS Latitude I ®I 0 Hauler door <br /> v 0 Inactive �0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use <br /> Business Type (Fill all that <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V j A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / F7 / M <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> § <br /> 0 In Compliance - No Violations <br /> 0 0 Other: <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: 0 Business Rep's Signature Phone Number Inspector's 5ig natur Ph_one Numb <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �a, I f, . 0.0.1 P I L I EI 111213 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />