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t 6 :Nu <br />Waste Tire Survey& Inspection Report insped <br />iUf State of California <br />California IntegratCM14ed8 181 (New 04104Management Board ) Survey Form - Page 1 <br />C i'' ism t�!N[ <br />Waste <br />J*CK INK PEN <br />[art A - Survey <br />Spec <br />S <br />tion Detail <br />on I <br />Sites <br />Routine 0 Re -inspection GQ Referral Observa on <br />TPID. Inspection Type (Fill one) <br />Suffix: ti <br />Local <br />If Referral, choose referral type (Fill one) <br />Identifier: 61 <br />0 CHIP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />, <br />QIA <br />d—usiness, or Facility —Name <br />Inspected By Inspector <br />Physical Address 11TO 1 LK'0_ <br />Inspection Date <br />Time In Time Out <br />,1 i� <br />j ZlpVode 0 AM <br />Business Rep -Title <br />0 AM <br />L j <br />a PM G) PM <br />Operational Status Tire Typo I Bustness Rolo Storago Typo <br />I <br />ly)' (Fill all that apply) (Fill all that apply) one only) (Fill all thalapp <br />(Fill <br />Tire dount C <br />0 Active 0 Passengor 0 Generator 0 Outdoor <br />r <br />of Closed 0 Altered <br />GpS Latitude t 0 Hauler 0 Indoor <br />0' 0 -Inactive 0 Truck <br />Longitude 0 Planned <br />0 End -Use 0 Corltainer <br />0 OTR <br />113upinossType (Fli'l B11 that 8ppiy <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader <br />WO 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 Doaler, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR .§ 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 <br />Other; § <br />Comments <br />MspeCtion Form Included: 0 <br />A <br />-7 <br />0 Dismantler 0 Tire Derived Fuel <br />()0A I <br />ENFORCEMENT STATUS <br />0 Notice Of -VI01011115n 0 Extonslon <br />tomp!fanc.e Deadline <br />Date <br />it <br />M M <br />egtiired tor" NOV orEXT) <br />0Referred! CIWMB Enforcement <br />In Compliance No Violations <br />os) <br />Comments Included. <br />Business Rep's Signature Picone Numbor <br />INSTRUCTIONS ON BACK Correct:* Incorrect: X X] 62081 <br />White Copy,- CIWMB Yellow Copy: Operator Pink Copy: LEA <br />W, <br />