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Waste Tire Su: y & Inspection Repo Inspection Report Number <br /> Stateo�California <br /> LiR CIBWM fi581(New041004) Survey Form - Page 1 f 0 3 0 0 2 <br /> California Inte ra d Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> - i <br />} TPID- � l h :OE <br /> Eul <br /> Inspection Type (Fill one) <br /> Site Suffix: _ � [( Routine Q Re inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �GIrL (�(k FYI (�- 11ft � Q CHP. Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name u Inspected By Inspector <br /> MV TAo,, ia-fiD, .� <br /> Physical Address R — O 1 ., e -.e- <br /> I ;? . tAj <br /> Street 9 5,p <br /> Jp t1 I Inspection Date F T0 ___)ISq Cx, hov, 01 m <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> mm0PM mem 0PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ❑ I I I I �/ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (§) Active Passenger Q Generator Q Outdoor <br /> F7 Q Closed Q Altered <br /> GPS Latitude m . Q Hauler &ndoor <br /> 0 Q Inactive Truck <br /> Longitude — Q Planned 0 OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer .Q Auto Repair (C) Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel I <br /> Q 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 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> FV-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 M / FTI / Ml <br /> Q Q 14 CCRJ§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 014 CCR-§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> (Required for NOV or EXT) <br /> d - <br /> Q Q 14 CCrR§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 /> \. J <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 00 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators t <br /> - ® In Compliance - No Violations <br /> Q Q Other: § ��` y f <br /> Comments �^ Y; °y,� c f,6'.7, `Pkk' �_ (> .�4�C �lJl�d L�,-O# y)t� /1 t7 <br /> �C4Li iG+ Uhl "I �r�;t�lr1 l �� t` W)l o VI Y <br /> fej <br /> Inspection Form Included: Q', <br /> �' <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> • `,, , � m ( 62081 <br /> INSTRUCTIONS ON BACK :Correct: Incorrect: 1 f `.y . , ,r , .. 1 2. 3 <br /> ■ White Copy:CIWMB Yellow Copy>dperator Pink Copy:LEA ® ■ <br />