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Waste Tire S y & Inspection Repor 'nspection Report Number , <br /> HGilBd State of California . ■ <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 r 9 1 4 132, 15 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business_P_rofile Inspection Details <br /> TPID- jj (.` _ Inspection Type (Fill one) <br /> Site Suffix: DE (j)Routine Q Re-inspection O Referral O Observation <br /> Local �` f - If Referral,choose referral type(Fill one) <br /> Identifier: ` t.1 '; 0,1 t ° i,1 { Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ; _ T — - --- <br /> ti Inspected By Inspector <br /> 1i;�1>f �` itF-AlF 17 <br /> Physical Address – ) j <br /> •:�Pt/L 1'�_l lc t t I <br /> Street . <br /> Inspection.Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> / / vii <br /> m m0 PM m • m 0PM <br /> �- f <br /> I � i �U �� yl�lr �Gl �1 �I/�1l�: Y � -- - ---- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ❑f f I C-J� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l I (� ✓� ,Active Q Passenger Generator Outdoor <br /> O O Closed 0 Altered <br /> GPS Latitude m • Q Hauler 0 Indoor <br /> D Q Inactive @ Truck <br /> Longitude – O Planned C).OTR 0 End-Use O'Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government Q Retreader ® Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station o Hauler Q Agriculture Q Shredder Q 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 /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 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 /> 0 Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> ----- ....................._.---------___...._._. <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (b In Compliance - No Violations <br /> Q 1 O Other: § <br /> Comments ,t.A.f. ` <br /> �� rant// oris rC_.j L91A 4G, i��; 0001 P t�ff � G.X `� I��� �� f � / I C4 <br /> Colli ll t�P s ((of h(avL ,(,t,{�Jf$ <br /> � ti- t,(>I"�'� � �'f�C� &(1wU4"j-a't) QUI <br /> —r <br /> lfwk fife ) apt? Sold C-O SIUyle�' S wo 'If C- j l'f e 0rje �'.r���:C�� of <br /> Fl L A;ra vtyc o n . jo IGt Loyt <br /> nspection Form Included: 0! <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Incorrect: ) E ,r4�M ,� 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> d <br />