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Ask <br /> x ■ ' �F <br /> Waste Tire S 'e-A Inspection Repo .Inspection Report;llumber ■ <br /> fiforn C1NMG1811i(teM nage) `Survey Form - Page 1 l 4 - 1 01 -0 0 � <br /> aic-y <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> f Site Suffix: f <br /> _ _ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ( If Referral,choose referral type(Fill one) <br /> Identifier: tr1, UC(q /(� .t r-( l D;t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Sk <br /> Business or Facility Name — ——. <br /> % -�- Inspected By Inspector <br /> I l l�4 tr(� V1'l e r l c r, ( ISP (��l f CQ_- I _ <br /> Physical Address l I 0 I I F/_Ct <br /> Street J r <br /> Inspection Dateo <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title �AM0 AM <br /> ,fC� VY I/�.. t �; <br /> �-d}��j m • m0PM ' m 0 P <br /> I �V� lJi✓;U.U. .-� (.�>✓i t i I L./ ° ✓r i --------- — --------- i,. <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' 101 1 Q Active Passenger (Z) Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude m • Q Hauler Q Indoor <br /> p Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> y New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <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 /> -- <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date mU] <br /> Q Q 14 CCR§18459.1 (a).(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3 Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments pr ' � � � _r �fr-7_ C,? <br /> titin ,>n ,.., J S_f <br /> P N MA (2150 aOic T_17 �,��� �fi✓� Ivy lP � �rC���j . C''lL <br /> ` L) <br /> Inspection Form Included �n c.r�: <br /> Comments Included '.-.. / .... '-L:_.. <br /> Business Rep's Signature Phone Number Inspector' Signature'' Phone Number <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: XX � , ,A ► ,, PF.,LjEj IlIZ13 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />