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fir Waste Tire Sury & Inspection Report inspection Report Number ■ <br /> E`f <br /> State of 82'(New04/04) Survey Form - Page 1 1 8 - -10 <br /> 4.8 .4 <br /> iiO <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 /> SIite Suffix: 15 � EEI Routine Q Re-inspection QReferral QObservation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: _ - r Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - . <br /> Inspected By � Inspector <br /> � <br /> Physical Address <br /> C r,c7ff <br /> Street <br /> L Inspection Date <br /> City State ZIP Code`f Time In Time Out <br /> Business Rep' Title 0AM 0 AM <br /> i m • m0PM IT-Tm 0-PM <br /> i •`� �Cv�.� � �t is J� iI i --- <br /> r-�-� 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 /> �U Q Active Q Passenger Q Generator Q Outdoor <br /> t O (C) Closed Q Altered <br /> GPS Latitude m • O Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer (a Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> bService Station Q Hauler Q Agriculture Q Shredder Q Other 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 /> Q Notice Of Violation Q Extension <br /> Q O I PRC§42951 -Waste Tire Hauler Registration and Transport of Tires �. <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O ; Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> Q O 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 <br /> (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q O 14 CCR§18.461 -.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 p,In Compliance - No Violations <br /> Q Q Other: § <br /> Comments h \ � ���.a^c; "�'i r�� �-t P .,&�.�.'� 1� ^'t- '7�,r'� r'- -�_��, � � �4—• <br /> F <br /> Inspection Form Included: <br /> Comments Included.O .. .... ... .: <br /> Business Rep's Signature Phone Number Ins ettor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK . Correct:* Incorrect: jE1Xj,AjMjPj,dE1 III ' <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA. ® S <br />