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�q14 Waste Tire Su y & Inspection Replort Inspection Report Numberstate of California <br /> [� EG <br /> � qGF. G CIWMB 1tt1(New 04/04) Survey Form - Page 1 C 1 8 - 1 0 1 4 7 3 21 ` - <br /> Califdfnia-Integrated Waste Management Board . <br /> Part A- S4urve 1 BLUE OR BLACK INK PEN <br /> _ Business Profile Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> t Site Sbffix:,e ( I" 7J �>l Routine j Re-inspection 0 Referral. 0 Observation <br /> t <br /> Local /�' .- �� If Referral,choose referral type(Fill one) <br /> Identifier: �. 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit O'Other <br /> Business or Ffacility Name Inspected By Inspector <br /> Physical Address <br /> Street <br /> I • <br /> r Inspection Date j <br /> � :,. <br /> City State ZIP Code Time In i Time Out <br /> Business Rep Title ( OmAM 0PM IT—] 0 P0 AM <br /> Operational Status Tire Type Business Role. Storage Type <br /> Tire Count(WltglelPTE)a f I I . I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 LJ—LJ r (a Active Passenger (a Generator Outdoor <br /> D 0 Closed 0:Altered <br /> GPS Latitude m • 0 Hauler 0 Indoor <br /> D 0 Inactive 0'Truck <br /> Longitude - 0 Planned )OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 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 I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <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 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 /> I <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§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q_ 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> 0 0 Other§§ <br /> Comments �4�1_c,%T 4'S-fG Cc�l <br /> rJ0 U J IG <br /> nspection Form Included: ' <br /> Comments Included: Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> VC � TTI 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ) y X .+ IM1�i. P .� e 1 a 3 <br /> ` . White Copy:CIWMB''. Yellow Copy:Operator Pink Copy:LEA ® S <br /> LX <br />