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Waste Tire SuSey & Inspection Reports Inspection Report Number <br /> State of California <br /> (New 04104) <br /> Survey Form - Page 1 1 6 - { R V V/ V 0 7 <br /> California IntegratedWaste Management Board <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- I I + �i Inspection Type (Fill one) <br /> Site Suffix: i 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local -7 i If Referral,choose referral type(Fill one) <br /> Identifier: j l i '! h (r' u v 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> � Inspected By Inspector <br /> Physical Address <br /> i <br /> Street l r' ( �� ,�r Inspection Date <br /> I & - <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> I0PM I QPM <br /> (OFpeone'onal only)Status (Ftre II Type <br /> Yhaprage Type <br /> p ((Fill all that apply) Fillss Role allall that apply) <br /> Tire Count (Whole/PTS '7 <br /> Active 0 Passenger 0 Generator0 Outdoor <br /> GPs 0 Closed 0 Altered ��•f <br /> Latitude Hauler Indoor <br /> � 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR t�End-Use Container <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 ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -------------- <br /> V 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 <br /> TI / m / M <br /> 0 Q 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 /> 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments (' <br /> 1 vt <br /> , <br /> Inspection Form Included: 0 <br /> 'I <br /> Comments Included: 0 - -------- <br /> _ Business Rep's Signature Phone Number Inspector',S gri . Phone Num_ b_ <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X 1�- \// E XI A MJ P�L I EI 1112 131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> Yt <br />