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® yy�!te Tire Su, ly & Inspe:,tion Report Mspection Report Number <br /> Bifornia - <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 1 6 1 Q u 6 5 3 o <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- G _ Inspection Type (Fill one) <br /> Site Suffix: ` 0. 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educatic^al Visit 0 Other <br /> Bess or Facility Name Inspected By Inspector <br /> Physical AUress � �30 � � \ <br /> 3 <br /> \ cs\ � S3 77 Inspection Date <br /> Time In Time Out <br /> Business Rep Title I *0 AM / /1 Q AM <br /> NA <br /> ( � PM ! �- —7 ® PM <br /> Sib '� <br /> U Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that appi, (Fill all that apply) <br /> �i p o <br /> ( Active ® Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude �' 0 Hauler 0 Indoor <br /> 0 0 Inactive 10 Truck <br /> Longitude – 0 Planned ® OTR 0 End-Use Container <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 ®Collection 0 Crumb Rubber <br /> 0 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 /> 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 0 / 117 / m <br /> 0 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 <br /> In Compliance - No Violations <br /> 0 0 Other: § <br /> Continents <br /> Inspection Form Included: 0 /' <br /> Comments Included: 0 ?—_' / � �Business R ''s Signature Phone Number 7;4 <br /> I nature ' Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ik E= !A 1,� r' L1 E= 1 2 f <br /> ® _ -_ <br /> White Copy:CIWMB Yellow Copy Operator Pink Copy LEA <br />