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FORM NO.M-105547-CIWMB M12 2401 519 987654321 <br /> : IiA Waste Tire Survey & Inspection Report Inspection Report Number <br /> tim State of California 7 - 1 0 ^ 5 /1 <br /> California Integrated WasCIWM8 181 te Managew ement Board Survey Form - Page 1 L (V, iV•; <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> -Business-Profile Inspection Details <br /> TPID- w r inspection Type (Fill one) <br /> Site Suffix: I <br /> utine Q Re-inspection Q Referral Q Observation <br /> Local 1,�f�pY�Sh choose referral type(Fill one) <br /> Identifier: <br /> TGC C�.t.t1 C B 144 Q CHPI �® CIWMB Q Complaint Q Educational Visit Q Other <br /> - Facility-- 1 1 - - -- -- - - _ - <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address .3 9 Z <br /> CA ��j Inspection Date /-`� Q / 3 <br /> ll Time In l J C) Time Out <br /> Business Rep Title O AM �l Q AM <br /> Roan �iIfA/ ►rkC ` ��✓'ewvu. - – — <br /> J Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> f 9) Active Q Passenger a Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Flee: Q 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 ®Agriculture Q Shredder Q Other <br /> I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility j ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration a,d Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> - ---- - - --- - ..--- ---- <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <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 In Compliance No Violations <br /> 211,1 <br /> Comments JT, Dyl I�q L Iii S - <br /> �-ae v'��S i RS C'61) t.` <br /> Mai�i" 2olO�f'�'�S /'r 177xrvt2 �► L00(i �Z Q <br /> Vel ls�►� 1v4., ire ►hvpicz5 �/i2yv l ��1 r� LtP.S-f & -e '7tz r.,t,,��y� <br /> ©f1t: <br /> 334 <br /> Inspection Form Included: Q 'G�"J _ I l a /`�l ((�4 _E` <br /> Comments Included: - <br /> Busin s 12ep's ignature Phone Number ctor' a re Phone Number <br /> INSTRUCTIONS ON BA Correct: _Incorrect: - / [E XfA /,�, F 62081 <br /> X ,�✓; <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />