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= <br />is== <br />Waste Tire Survey <br />& Inspection Report Inspection Report Number <br />State of California <br />CIWMB fsteManage1 Survey Form - Page 1 <br />Board <br />1 2- 1 0 2 5 7 8 1 <br />California Integrated Waste Management <br />Part A - Survey <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Detalls <br />TPID - <br />Inspection Type (Fill one) <br />Site Suffix: <br />0 Routine 0 Re -inspection 0 Referral Q Observation <br />I <br />Local <br />If Referral, choose referral type (Fill one) <br />Identifier: <br />10 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name \\ <br />RD Vr _ � 'Ma r� l/�-e��T1 <br />Inspected By Inspector <br />Physical Address <br />— (� <br />� ���,� � Inspection Date Q � I Q <br />ra L� yy1 C <br />I Time In Time Out <br />Business Rep Title <br />0 AM 0 Alk.1 <br />1 <br />0 PM 0 PPv1 <br />Tire Count (Who(e/PTE) <br />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 />0 Active 0 Passenger 0 Generator ® Outdoor <br />GPS Latitude <br />� 0 Closed 0 Altered <br />0 Harlief 0 Indoor <br />J <br />l <br />a ®Inactive Q Truck <br />Longitude s <br />0 Planned 0 OTR End -Use e Container <br />Business Type (Fill all that apply) <br />i <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 <br />0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture <br />0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility i ENFORCEMENT: STATUS <br />V I A HAULING AND MANIFEST REQUIREMENTS <br />0 0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires IS Ndtice Of Viototlon 0 Extension <br />0 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. t:oinpllenCe Deadline <br />0 0 PRC § 42956 - Registration/Decal in Vehicle m) <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 days (Required %r NOV or EXT) <br />0 0 14 CCR § 18459.3 -Retention of Manifest Forms and Tire Trip Logs for 3 years <br />__ ._.. <br />0 0 14 CCR § 18460.2 - Manifest System Requlremenfs for Registered Waste Tire Haulers 0`-R�ferred I Cf1NlM8 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: § Qjnl X ompllan4 - No Violsoone <br />//4 <br />Comments WQ J-k,%re. C�fl ��� / !4 �� 'O//wJ L""4,� <br />y �Gsti" d <br />YWr�� ctY�e a►pS a� 1 pe1S�\1 ` l� �v-��g okv c� c)h� Sew11 <br />Inspection Form Included: / <br />Comments Included: 0 <br />Business Rep's Signature Phone Number spa i not Phone Number <br />INSTRUCTIONS ON BACK I Corrects I! 0r ( WI�P L� 1 2].3 62081 <br />IEnt White Co CIWMB Yellow Copy: Operator Pink Copy LEA <br />KB8 Copy: <br />