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Atm 1041111110f�... _. _. lam.". : . BMW_ <br /> Waste Tire Su y & Inspection Reporo Inspection Report Number <br /> ;;z] State of California <br /> nmol Cgrated Waste <br /> Survey Form - Page 1 ( 7 - 1 0 1 3 ) 1 7 <br /> California Integrated Waste Management Board __..____. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: [I[Z ` 4 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: _ v� L'�' ( Y�. ;�l✓4 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> fPhysical Addrest U /1 I a' t, <br /> 1 L ii( f Pl r - <br /> Street <br /> / Inspection Date <br /> City State Zlp Code Time In Time Out <br /> Business Rep Title Q AM /� AM <br /> 0 PM (b PM <br /> Operational Statusire Type Business Role Itorage Type <br /> , <br /> Tire Count (Whole/PTE ` r (Fill one only) Fill all that apply) (Fill all that apply) Fill all that apply) <br /> (� V Active P Passenger 0 Generator Outdoor <br /> D 0 Closed 0 Altered <br /> Latitude <br /> GP$ 0 Hauler Indoor <br /> _ O 0 Inactive 0 Truck <br /> Longitude - LL 0 Planned 0 OTR 0 End-Use 0 Container <br /> _-A <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder (a Other I , {.(t <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 I 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: <br /> Comments § <br /> + { - <br /> �� IIVI.�' hi � C7~!V><t , �,i � U'Cd j j (� �J ! ;4'U�+�i"/ (��U � G'i U�e-� r. <br /> ( V <br /> rC�f:( (.;, , �y Ll ,fi <br /> ir-Cri�✓U+C�VA f ltrr <br /> C'T�� IM <br /> wP G <br /> Inspection Form Include <br /> Comments Included; <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E_X_�A. VIIII'l LJEJ If 2 3 620< 1 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />