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Waste Tire Sw , Inspection Report Inspection Report Number <br /> State of California <br /> CWMB grated Waste <br /> eManag ) Survey Form - Page 1 1 5 - 1 0 0 6 J a � <br /> California Integrated Waste Management Board <br /> Dart A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I d .� �I Q Routine Q Re-inspection Q Referral Q Observation <br /> Local ^ If Referral,choose referral type(Fill one) <br /> Identifier: �1 DQ Ut f1 / ^vn L . �C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 3 (� <br /> Zq 79 -A v / (f4n 4e r rc, <br /> � �A^ g Inspection Date J-®C'�` V" 5Zr '�' Time In / Time Out <br /> Business Rep Title O AM ° Q AM <br /> QPM 0 PM <br /> ! nvi <br /> Operational Status': Tire Type I Business Role Storage Type <br /> Tire Count (Whole/PTE) f (Fill one only) (Fill all that apply), (Fill all that apply) . (Fill all that apply)' <br /> Q Active Q Passenger , Q Generator Q Outdoor <br /> ® Closed Q Altered <br /> ��� Latitude Q Hauler Q Indoor <br /> U Inactive Q Truck <br /> LongitudeQ Planned Q OTR i Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> _ .-_.. ........ ......... .- <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 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and Enol-Use Facil°oty ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 /> M / m m <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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § -- <br /> Comments Al 0 47 <br /> inspection Form Included: Q', <br /> Comments Included: Q, ° _......._.. ..- ---. .-�v. �. <br /> Business Reps Signature; Phone Number Intor's Signature Phone Number <br /> --- --. -- -- — - -- _ - - -- - <br /> INSTRUCTIONS ON BACK Correct:I* Incorrect: "� �+, M. I. 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> ■ <br />