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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Int State of California <br /> ClWMB IstNew Manag j Survey Form - Page 1 1 2 - 1 0 2 5 6 2 3 <br /> California Integrated waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Z ( Inspection Type (Fill one) <br /> Site Suffix: ` 3 ao Z 11ti Routine ® Re-inspection 0 Referral 0 Observation <br /> Local if Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> � _ ` o ` � <br /> Ph sical Address 1 d, �LVla'li ` <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 PM I QPM ' <br /> Operational Status i Tire 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 /> } #Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Q Truckin Fleet' 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> w <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 i ENFORCEMENT STATUS_ <br /> V i' Al HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extan#[oat <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 r' <br /> 0 0 PRC§42956-Registration/Decal in Vehicle rn <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Defe / <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB �--� —J f <br /> 0 0 14 CCR§18459,2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> (Requlred for NQV o. <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 Q�efarr0d(Gl1fVIVIS Ftltq�d6t#�At�fr <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 I 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other: § <br /> Lo�_0t T r- <br /> Comments t�f . t.C�ti.Q C- S lh V tJ► w 5 c Ir 1.GPr�r') <br /> .�i1n V v A -3 Z lti t-t R ` N 01A b`n c-- v i Y I t 5 �l,v U-S <br /> Inspection Form Included: 0 <br /> Comments Included: 0'�7�G -=�/ <br /> Business liep's SigrYature Phone Number Ins actor's Signature Phone Number <br /> _ . !'' I� �T2 62081 <br /> iNSTRUCT?&RN BACK Correct:. Incorrect: ( , �/) t R Ni F I 1 2 3 <br /> KS <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br />