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Jar: m <br /> Waste Tire SL*. y & Inspection Repor Inspection Report Number <br /> kim <br /> y State of California _ <br /> CWMB Waste <br /> eManage) Survey Form - Page 1 1 6 - 1 0 1 0 7 7 0 <br /> California Integrated Waste Management Board — -- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- .• � Inspection Type (Fill one) <br />} Site Suffix: i _ J - Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: f !( (i k!�, (^�-r, ( 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address ( ' / - FTITI-1 <br /> ) <br /> t <br /> Inspection Date <br /> State ZIP Code Time In Time Out <br /> Business Rep Title m , m Q AM O AM <br /> �JL- �J0PM m ' � - 0 P <br /> Operational Status Tire Type Business Role torage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) Fill all that apply) <br /> Tire Count (Whole/PT � `� <br /> 0 Active 0 Passenger 0 Generator Outdoor <br /> TTI� 0 Closed 0 Altered <br /> Latitude J—J . <br /> (3P.S 0 Hauler Indoor <br /> O (0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business <br /> ' ' ' , LLL <br /> 0 New Tire Dealer 0 Auto Repair 0 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 (3 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> p Y <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 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. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 - Responsible Entities Complying with Manifesting Requirements Date M / m / m <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 days (Required for NOV or EXT) <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/CIWMB 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> jr f ��'jllj( IIG1'.. "I <br /> �• .i r j i t ( `�ir!' I^� jlfe' jj' {✓VI otrr <br /> k. <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> - - 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X E'x A 'G01 P .L E; 1112131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> I <br />