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_6 <br /> Waste Tire Sy & Inspection Repo )nspection Report Number <br /> -- - <br /> EoLft. <br /> 77:: State of California <br /> . .oar CIWMB asteManage Survey Form - Page 1 1 3 - .1 0 0 5 6 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: 0 Routine Re-inspection 0 Referral 0 Observation <br /> Local Z =1 i If Referral,choose referral type(Fill one) <br /> Identifier: -# 1. JI (�CIf.J, (,;' �i } Ti 4' "' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other + _ <br /> Business or Facility Name f <br /> Inspected By Inspector <br /> Physical Address jCE _ I I <br /> VC <br /> j <br /> Street Inspection Date <br /> l r � <br /> Si to ZIPCode <br /> � li Time In `. Time Out <br /> Business Rep Title C—� Q AM Q AM <br /> I� Q PM T Q PM <br /> J r <br /> Operational Status Tire Type <br /> Business Role <br /> pStorage Type <br /> (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 Inactive 0 Truck <br /> Longitude – f 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <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 /> i r <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 <br /> FFI / m / FF] ; <br /> 0 i 0 1 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 I CIWMB Enforcement <br /> O O 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 1 0 Other: § <br /> Comments <br /> C .1 ! �( G / 71 + <br /> Cll. il � yyt (/�(A ilr� ( Yll� ( � C!jtL'- <br /> , r, <br /> J-� '�-L �L� r ��dc'(n.; �,r.�Lr -fir S 0Y ( <br /> "rah U� ��.c _ ( V l l l ��c ��j 'I C <br /> F.,I�/'�(n�� �" ,il4�Jk w�.� r�'ri,"ti''�? ';<„� r 1 r.k: P + � 1, ti r iq'M .✓ '"^rir �v ,.w'H ,�rr , <br /> ®R <br /> � ,� '.✓ <br /> dl <br /> ,5 r ✓ it ~ � �:lr ¢,p ra' »L <br /> i <br /> '„` ,, @.�M, �+ ✓hku r.t rr- r ,kn yrs r k c,;;: r y,,,y.M,?n3 �`,�,,k n <br /> _...m,:.,.�,�.,y�' <br /> � <br /> INSTRUCTIONS ON BACK <br /> Correct: Incorrect. ( x "� ,�,� 62081 <br /> White -- --_ ■ <br /> $.. ■ Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br />