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A "E5 <br /> Waste Tire SL_*ey & Inspection ReportP-lnspection Report Number <br /> ErtC ■ <br /> SFr State,of California <br /> 7 <br /> s. CIWIVIB grated Waste <br /> eManage Survey Form - Page 1 - Q . <br /> { California Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> 71- <br /> Business Profile Inspection Details <br /> TPID- . - 'Inspection Type (Fill one) <br /> Site Suffix:. <br /> __--- — --__ Q Routine Q Re-inspection Q ReferralObservation <br /> Local — <br /> Identifier: t �a 1 If Referral,choose referral type(Fill one) <br /> __ n <br /> 10 CHP O CIWMB O Complaint Q Educational Visit 0 Other <br /> Business or Facility Name—_ <br /> Inspected By Inspector <br /> Physical Address <br /> Street l <br /> { SILc F to i Inspection Date <br /> City State ZIP Code Time In Time Out V <br /> Business Rep Title <br /> AM Q AM <br /> jr? I )v (ems )1164,1• <br /> Gtrf►r � .._� — -f � 0 P ( � � V QPM <br /> ~Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ❑f I I I '.Z I f {� �} (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1------.J-� u V ® Active Passenger 0 Generator r :Outdoor <br /> GPS Latitude m , O 0 Closed Altered <br /> Hauler 0: Indoor <br /> D I Q Inactive Truck <br /> Longitude _ <br /> Q Planned OTR End-Use ( Container <br /> Business Type (Fill all that apply) <br /> i <br /> ® New Tire Dealer O Auto Repair Q Trucking Fleet O Government etreader Dismantler <br /> 0 Q Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> I 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 /> V A >HAULING AND MANIFEST REQUIREMENTS <br /> - - _ <br /> 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires () Notice Of Violation 0 Extension <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 14 CCR§18459 -.Responsible Entities Complying with Manifesting Requirements / <br /> Date / J <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 O 14 CCR§18459.3-,Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> I <br /> 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> I` 0 O . 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: §. Q in Compliance - No Violations <br /> Comments r <br /> ►rUI aYo( ,{,fir IV,✓ r , <br /> �/ ! to If�t<Fl� t ),� � Latt,�,� <br /> lec.l P 5017` ALow 1?7Q.r7Jf �'t� �C 100'ri of Iver; �(,t i,c t'r� Ir1 �t � i t <br /> ly <br /> yU to JItlo m <br /> nspection Form Included: '/ '' 7�� //1 t-' i 20 <br /> Comments Included 0:, ...lR.(�.�./,� - - {r'� .Iii .) V t <br /> usines§Rep's Si nature Cr--" <br /> p' 9 Phone Number Ins ectorJs Signature Phone Number <br /> INSTRUCTIONS ON BACK Fo�jrre7ct�.,& In�corretjcX( ) w � y'�t 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />