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LX= Waste Tire Su & Inspection Report /ispection Report Number <br /> tees <br /> NaState of California <br /> CIWMB <br /> Waste <br /> eManag) Survey Form - Page 1 1 3 - 1 0 1 3 3 0 9 <br /> California Integrated Waste Management Board <br /> PartA- Surve _ _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: l O 7 L 3 0 _ 40 Routine Q Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: - -� �y 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Busines or Facility Name Inspected B <br /> P y Inspector <br /> FNKC'v S i ted T�ra r�c� <br /> Physical Address ' 9 6 ( Scl S <br /> ,209P <br /> Inspection Date a Z / y / O <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> Awer l Z /ie/Gt�tR�cQ�r QPM QPM <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 /> ® Active ® Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> /-r O Q Inactive Q Truck <br /> Longitude ` / Q Planned Q OTR Q End-Use Q Container <br /> 1 I <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler Q Agriculture Q Shredder O Other <br /> Part B-Inspection of Waste Tire Dealer,.Generator, Hauler and End-Use Facility ENFORCEMENTS US <br /> RULING ANI] NTS <br /> Notice Of Violatio Extension <br /> • O PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance De <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days R ui ed:f r O <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> x{ <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers .Referred/CIWMB Enforce ''` <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> ® O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance <br /> Q O Other: § <br /> Comments 2,66 h* -to -h 35 1 S V/O4/01 <br /> rn _dam �irl�atl. CeQsz h ' `� �,� x��/��P� -� d►�_ �;���I /Is c <br /> i <br /> Inspection Form Included: Q <br /> Comments Included: • <br /> Busi ss p's Signature Phone Number Ins ores Slgn ure Phone Number <br /> jE <br /> INSTRUCTIONS ON BACK } P I 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />