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�E_ Waste Tire Sup . ,� & Inspection Report Inspection Report Number <br /> ue. <br /> State of California <br /> La <br /> Cgrated Waste <br /> eManag ) Survey Form - Page 1 1 6 - 100666 1 <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 one) <br /> Site Suffix: 2 2 '� - © Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S( J Co v.,t,)r�j O CHP Q CIWMB O Complaint Q Educational Visit O Other <br /> .Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> L <br /> Inspection Date o 7, J b L <br /> Time In Time Out <br /> Business Rep Title v.� O AM O AM <br /> �� <br /> n I C7 Z- @1PM O PM <br /> I ar t W, pec�c i �,\o b`^�vo-'►C <br /> Operational Status The 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 /> f f ®Active 0 Passenger #Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> 0 Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility NFORCEMENT STATUS <br /> -- -- - - - <br /> )iAULING AND MANIFEST REQUIRE t <br /> O O <br /> 'Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires fi <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ate <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days {Required for NOV or EXT) <br /> O O ---- - -- --- -- <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers a#erred) E emen <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators CoNmpliance - No Violatio <br /> O O Other: § <br /> Comments -, <br /> W U L r^ <br /> S� j,�,•� `ti�� _ '� LTL' S �.GA .� A.�w. 1 a'1ra•�.. <br /> w v)L— t 0.� 4V - 1. ►J��^�W t 't�Xi Vve ,-w- C. <br /> Inspection Form Included: O <br /> Comments Included: O 411C--t� ! <br /> Business Rep's Signature Phone Number Inspe or's Signature• Phone Number <br /> INSTRUCTIONS ON BACKjEjXjAjMjPj'L1Ej 111 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />