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i.EeR <br /> 'rWaste Tire Su Ay & Inspection Report• nspection Report.Number :.,. <br /> State of California <br /> HIM GVVted181 Wa(Waste <br /> eManag) Survey Form- Page 1 l 6 - 1 0 2 56 <br /> `Q 4 <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 /> Site Suffix: / " <br /> `( �� � (a Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or-Facility Name -- --` <br /> - Inspected By Inspector <br /> Y' <br /> ) ' <br /> Physical Address f : . <br /> Str <br /> <_f__1 c� Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title OAM <br /> 0 AM <br /> FF�0 PM Q PM <br /> r rye <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> s � <br /> Q Active Q Passenger Q)Generator `Outdoor <br /> Latitude <br /> O <br /> Q Closed Q Altered <br /> GPS Q Indoor <br /> m - <br /> O Q Inactive Truck Q Hauler <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> . . . - <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q 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 /> Q Service Station Q Hauler Q Agriculture Q Shredder Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V i A HAULING AND MANIFEST REQUIREMENTS <br /> — ---- -- Q Notice Of Violation Q Extension � <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <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 /> may+ ------- -------- - - -------.._.- <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> •�•� iti. G {..`. .4� �j/ /C.<, r.!_ �i' "".>i r t '/J /-'�. j (^:�• <br /> �f <br /> /�-✓"i� l.. `�i. ! !"E-�' �i,r E:. r��% "y j- �r 7.� <br /> 41 -1 <br /> fit_ <br /> �►^ti � i'Y"!P t`f(..�/G^ .�' 1.....�('-.1 I .. � aG,C-r <br /> Inspection Form Included <br /> Comments Included <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: JAIMI PILI El IIIZ131 <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA S <br /> i <br />