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Waste Tire Suay & Inspection Reporlwspection Repor'� Number <br /> -I State of California <br /> CIWMB <br /> grated asteManage Survey Form - Page 1 8 - 1 0 1 3 ! 9 1 <br /> California Integrated Waste Management Board <br /> "art A-Surve 'BLUE OR BLACK INK PEN <br /> � Inspection Details , <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: I + l I I I S J I d 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local (� If Referral,choose referral type(Fill one) <br /> Identifier: \n CA ��` , ,1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Li (� Inspected By Inspector <br /> Physical Address r, I I U I ( QV"1 r' I`• <br /> ,Street <br /> Inspection Date <br /> State ZIP Code <br /> Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> r. •uc <br /> /y 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> 71 (4 Active 0 Passenger III ® Generator 0 Outdoor <br /> GPS Latitude 0 Closed 0 Altered O <br /> I Hauler Indoor <br /> 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-UseDontainer <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 STATUS <br /> V A HAULING AND MANIFEST REQUIREMENT'S <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 / 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)u h r4 <br /> +Tot � i <br /> - <br /> IAO S14 <br /> V <br /> I �ulv �tO,Gt� ibJ�i c� o <br /> Inspection Form Included: <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 E X1 A M,I P! L I El I t 1 2 13 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />