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ER12904l088 <br /> ru <br /> Waste Tire Survey & Inspection Report . . inspection Report Number. <br /> rr Clate of MB18atonl' Survey Form Page 1 15 - 1 010. 8 6 9 <br /> Cgrte 1E1 Waste <br /> _ Calllomia 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: / y 7 - ( •Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � Q )j 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspec�o1 <br /> Physical Address U p 12:1�y <br /> A,4, �'�f err I -_ <br /> Street <br /> � <br /> Inspection Date <br /> ity �p State ZIP Code Time In Time Out <br /> Business Rep Title OAM O AM <br /> f � /�sq� SIQbcc�rrr m m O PM m'm O PM <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 /> / �5 <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude m O 0 Closed 0 Altered <br /> GPS 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-use 0 Container <br /> . — -._— <br /> Business Type (Fill all that apply) _ <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 /> Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> IMM1101111111ING AND MANIFEST REQUIREMENTS Notice Of Violation Q 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 <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 114 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required torNOV o EX <br /> 0 O <br /> 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 Q Refer ed 1 CIW B Enfo cement <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 In Compliance No Violations <br /> 0 0 Other: § <br /> Comments <br /> /Lc01`G `f�G� '/ �ft�/lll�flL �/y�.J Q"'fL Kt-a✓G� p�/ ?T�'{ �.�TG ['�.r/k c>L` <br /> A"a".rger!` <br /> Inspection Form <br /> Included:Q <br /> O � �Sign.ture\ <br /> j zo 14t7f7Comments Included: _usmess Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK Corr a c• reef: E X A M P L E 11[2131 62081 <br /> ■ - White Copy CIWMB Yellow Copy:Operator Pink Copy LEA ® ■ <br />