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Waste Tire Su. ey & Inspection Report , Inspection Report Number <br /> •-�i7 State of California <br /> Cgrated 1steManag) Survey Form - Page 1 1 4 - 1 0 0 6 5 4 4 <br /> California Integrated Waste Management Board <br /> Part A- Survey -_ -_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- L/ O cy Inspection Type (Fill one) <br /> -7 <br /> Site Suffix: t c ( / ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CIWMB O Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> A _�Ik5 /A o��ctr�tq�5 _ <br /> Physical Address 3 l CL) <br /> Inspection Date / D <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM O PM <br /> 1\ <br /> - - --- - - - - --o A-1 1, VoAivW Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> -5 i <br /> ®Active Passenger Generator IIS Outdoor <br /> D Q Closed � Altered <br /> GPS Latitude - Q Hauler O Indoor <br /> )O <br /> O Inactive ® Truck <br /> Longitude — .. O Planned OTR ® End-Use Q Container <br /> CC7 cc <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station O Hauler 0 Agriculture Q Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility j ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation Q Extension <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> QO 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date FFI / FFI / M <br /> O Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or DCT) <br /> Y k;� <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years r r a t s r <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers tt�tefene I B`': n4 mein <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities ` <br /> O Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators a <br /> ® In Comphafice No`•Violations <br /> O O Other: § <br /> Comments <br /> l t`4S--b�_o F✓� `I/�1 old�ci✓L--1 1 OOO S_ PA—- <br /> -- <br /> ���f v 5�"-w�urz�u -.r e.c m. � _[u•��ce5 __r-tvAl) VC1A- -Com- <br /> Inspection Form Included: Q ZO IJ ,^ - <br /> Comments Included: 1— <br /> Business Reps Signature Phone Num er Insp at Phone Number , <br /> ` -- <br /> 5��4 <br /> INSTRUCTIONS ON BACK _Correct - Incorrect: A C', E P L 1 Z 3 62081 <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br />