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Waste Tire Survey & Inspection Report Inspection Report Number <br /> •'l��� State of California <br /> Cgrated i(Now <br /> Manage) Survey Form - Page 1 1 6 - 1 0 1 4 6 8 6 <br /> California Integrated Waste Management board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> (Business Profile Inspection Details <br /> TPID- _ Inspection Type (Fill ono) <br /> Site Suffix: Z 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �' If Referral,choose referral type(Fill one) <br /> Identifier: `0'1�✓� ct hJL_ ^��� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> ��{w Inspected By Inspector <br /> Physical Address s �f 1 C:� / �l <br /> 4__ <br /> Inspection Date / ! © <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O Plv4 O PM <br /> Operational Status Tire Type Business Role 1 Storage Type <br /> Tire Count (Whole/PTE) / (Fill one only) I (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Passenger� ' ® g ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> Gp.S Latitude a Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude _ _ Q Planned Q OTR Q End-Use ® Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet I& Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agricufture Q Shredder Q Other i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT.STATUS <br /> .....� <br /> V1 A 1 HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q 1PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements pate <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB I I <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV gFEX7) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred l CIWM6 Anforcetn96t <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators _ <br /> lff 4'I'rxrpll�lrfae <br /> Q Q i Other: § <br /> Comments ,� n�r�"'� pc•�i/7G �� C�!Ti'a�.�5 �{�n l J r"td � �..c�l�C`'C:.��'�j�S`t�•-� <br /> ­7�Z�✓1n . ' , f'11a--4 <br /> �Inspectlon Form Included: <br /> Comments Included: <br /> Business Rep's Signature Phone NumberIn ac or's Signat re phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: ( E X A M P E 12 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />