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Waste Tire Su.r & Inspection Report�._p _p <br /> section Report Number <br /> -:y� y State of CaliforniaCIW MB aj j/�� f/� jf�� jf�1 <br /> w 04104) <br /> California Integrated tWaste 81 eManagement Board Survey Form - Page 1 1 9 - f Y 1 3 f V- V <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile [7( <br /> nspection Details <br /> TPID- nspection Type (Fill one) <br /> Site Suffix. j 1� �' ( 71 .0- <br /> t Z Routine Q Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: _�_ F J s { 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name a Inspected By Inspector <br /> Physical Address <br /> Street <br /> _ Inspection Date <br /> Cit State ZIP Code Time In _ _ Time Out <br /> Business Re0 AM 0 AMp Title O PM O PM <br /> i <br /> Operational Status Tire' Business Role Storage Type <br /> (Fill one only) (Fill all � � (Fill all that apply) (Fill all that apply) <br /> Q Active 0 P Generator 0 Outdoor <br /> 0 0 Closed <br /> Latitude <br /> GPS iPi'` ® Hauler 0 Indoor <br /> 0 Inactive 0 Tr�r1c"yy <br /> 0 <br /> Longitude Planned 00 Q End-Use 0 Container <br /> R <br /> Business Type (Fill all that apply}" <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 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 A HAULING AND MANIFEST REQUIREMENTS <br /> 9 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 <br /> M / m / 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments i, <br /> Inspection Form Included. 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> / 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X a1 .� r�ydyi=" p�j ETI 172 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� S <br />