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ori�'nspection Report Number <br /> Waste Tire Su Jy & Inspection Rep <br /> I• State oCIWMBf California I <br /> Calif Ine grat dWaseeManagementBoard Survey Form - Page 1 3 1 0 1 3 f V 5 <br /> Ed <br /> part A- Survey BLUE OR BLACK INK PEN <br /> TPID- f I d I /f I (.� I I ('� Inspection Type (Fill one) <br /> Site Suffix: r ) ( 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local - I 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 JI i Inspected By Inspector <br /> Ahysical Address <br /> Inspection Date <br /> State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 0 PM <br /> - <br /> Operational Status A Tire Type Business Roletorage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) Fill all that apply) <br /> ® Active 0 Passenger , Isis Generator Outdoor <br /> L' 0 Closed .0 Altered <br /> GPS Latitude I I I . I I O 0 <br /> Hauler Indoor <br /> v <br /> 0 Inactive 0 Truck <br /> Longitude — 0 Planned P 0 End-Use 0 Container <br /> Business <br /> y <br /> 0 New Tire Dealer 0 Auto Repair 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 S'I"AYUS <br /> V ! A !HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 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 Vehidle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 I CIWMB Enforcement <br /> 0 0 14 CCR§184 ,jl -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 it ( ''lr !) /j f- '.. 1'�`j+" �;�fl;li,�(�i I,,S�/fir, /?►� � � �(/� 't�r <br /> �,a� ;`? (`�- �;•i.,�(?�.�" I �Ull,��� , ,`,�`:_ll(� !�'�i�`.{f' i�if ? �t :/�-'ry� r�!'�6 '` 'Ij'+-�FJt4�( )r ,� �' <br /> `1 <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct'.I* Incorrect: X 1�, \/ i= XI .l.' -' L I EI I l l 2131 <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />