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® <br /> r-rjWaste Tire Survey & Inspection Report Ifspe�ion Report Number.,••• j_ ■ <br /> - r <br /> State of CalHornia <br /> ClWMB , teM nage Survey Form - Page 1 15. 1 ;0 1 0 5 8 8 <br /> California Integrated Waste Management Board <br /> Part A-Survey. BLUE OR BLACK INK PEN <br /> Business-Profile Inspection Details <br /> TPID• ' l� Inspection Type (Fill one) <br /> Site Suffix: / Routine 0 Re-inspection 0 Referral 0 Observation . <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: TO 0. 0 CHP 0 CIWMB 0 Complaint 0 EducatlonN Visit 0 Other <br /> Business or Facility Name V Inspected By Inspector <br /> JiCe _ DO <br /> P ysical Address <br /> Street <br /> Aem cel a3 Inspection Date % O �7 /} <br /> I (� V <br /> City /` —State ZIP Time In Time Out <br /> Business Rep Title O AM <br /> Q AM <br /> /Ji'L„,� W ri {A O PM QPM <br /> �/ rJCJt —1 u Ute--1f`—�ti �—�t Operational Status Tire Type Business Role Storage Type <br /> ( ) I I r, l f- , , I. (Fill one only) (Fill all that apply) (Fill all,that'apply) (Fill all.that apply) + <br /> Tire Count Whole/PTE U �lU( w„ <br /> Active 0 Passenger ®Generator &Outdoor <br /> O 0 Closed 0 Altered ' <br /> GPS Latitude m• 0 Hauler 0 Indoor <br /> O 0 Inactive ®,Truck <br /> Longitude -O-Planned--- 0- OTR Q 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 /> 0 Service Station 0 Hauler .0 Agriculture. 0 Shredder 0 Other L -(And Timer '--1i" <br /> I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V <br /> M 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 j <br /> 0 0 14 CCR§18459 -Responsible Entities Complying With Manifesting Requirements Date m / IE <br /> / 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 FX7) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> i <br /> 0 0 14 CCR§18460:2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred!CIWMB Enforcement <br /> f- 0 0 14 CCR§18461-Manifest System Requirements for Waste-Tire End-Use Facilities _ <br /> i 14 CCR§18.462-Manifest*System Requirements for Tire Dealers or Waste:Tire Generators <br /> (�Dln Compliance - No Violations <br /> 0 10 1 Other. § <br /> Comments <br /> GfL .fr Iv <br /> Pri'kS uta�S_ _�7Xes m `mss <br /> fo,r� `iy►�ez C� �trin� nes r 1 _ _ Q T <br /> �ri-I�L C a dm ch V-S ane_ a <br /> aa 416 <br /> - -s <br /> Inspection Form Included:0 i -f <br /> Comments Included:® Aig� <br /> Business Rep's Signature Pone Number Inspector gnature Phone Number- <br /> 62081 <br /> umber62081 <br /> INSTRUCTIONS ON BACK Correet:� I correct: X R dh P L E f 2 3 <br /> ■ White Copy CIWMB Yellow Copy.Operator Pink Copy.LEA <br /> __ E i <br />