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a�z Waste Tire SAey & Inspection Reporp Inspection Report Number ■ <br /> a , <br /> Cgrated 1(New <br /> toMana4) Survey Form - Page 1 <br /> California Integrated Wasle Management Board <br /> Part A- Survey OR BLACK INK PEN <br /> 'Business(Profile Inspection Details t <br /> T - Z _ d Inspection Type (Fill one) G14 f= � <br /> Siteite Suffix: 1* Routine 0 Re-inspection e erre a ion <br /> J • <br /> Local If Referral,choose referral type(Fill one) ed <br /> Identifier; ... <br /> 0 CNP 0 CIWMB 0 Complaint 0 duc io I i,'t O r <br /> Business or Facility Name / � <br /> /t tv✓b /neSer- PmAlt- Inspected By Inspector <br /> Physlc'aaddress <br /> Inspection Date a 3 ' :2—;7-_ I a� <br /> Gy Time In Time Out <br /> Bus)116ss Rep }} Title <br /> V7 e, oW"�'1tr'/ Q AM Q AF�4 <br /> PM Q PM <br /> Operational Status Tire Type ype Business Role Storage Type <br /> Tire Count (Whole/PTE) r ' a (Fill one only) (Fill all that apply)i (Fi)t all that apply) (Fi)l all that apply) <br /> • Active 0 Passenger 0 Generator 0 Outdoor <br /> D 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 inactive 0 Truck <br /> Longitude - 0 Planned0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility j ENFORCEMENT STATUS <br /> Y A HAULING AND MANIFEST REQUIREMENTS ' O 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. Com lienee Deadline <br /> 0 0 PRC§42956-RegistrationlDecal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <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 daysr NOV or EX7) <br /> (Required fo I <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 1 COMB 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 /> 0 0 Other: § 0Irorrrpillsoce No Violations I <br /> I. <br /> Comments <br /> 1'✓a—JG 7jrc -cry ,► c.-r� ` <br /> 51A__ uO� I')G�/ vv�'�iG✓ a✓laC face✓�7�tsii'lC� •rave <br /> 1411 I. / � ►mss �-f 1� 1 �r s d�I -- - - , <br /> Inspection Form Included; 0� <br /> Comments Included. 0: f� .' X18 <br /> i Business Rep's Signature Phone Number o ' Ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct; in��rreck l ^ _- A M PL j 3 62081 <br /> . �_. . L Il. -L _! <br /> ® While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />