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Inspection Report Number <br /> Waste Tire Sur _y & Inspection Report <br /> ka <br /> State of California <br /> Cgrated Waste <br /> Survey Form - Page 1 1 9 - 1000^ 656 <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: ` 'L 4, A\ p Q Routine ® Re-inspection Q Referral Q Observation <br /> Local r. If Referral,choose referral type(Fill one) <br /> Identifier: SGS �c�cy ,, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 216 t'k 7 - -k 7 c7,<-av -)k ' <br /> Inspection Date •l Z � � � � � <br /> 0 <br /> Time In Time Out <br /> Business Rep Title Q AM O AM <br /> O PM \ Z "Zi J ®PM <br /> Operational Status 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 ® Passenger ® Generator (&Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date / <br /> 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m m m <br /> Q Q 14 CCR§ <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV orEXn <br /> i ' <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q �I '7 <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire HaulersaReferred/CIW``MBII Enforce <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities lU�l' tll <br /> Q # 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance No Vlolatlo, s <br /> Q Q Other: § <br /> Commentsl.uv> <br /> W <br /> V-'7 <br /> 0.w Lti( {' S ��ot,�-� �,� nZk 1.� S ; <br /> r V'k <br /> Inspection Form Included: 2 <br /> Comments Included: Q' �s 4 Phone <br /> e NumberBusiness Rfep <br /> Inspe or's Signatu Phone Number <br /> �,--=---T _ =-- r;,� 62081 -__— <br /> INSTRUCTIONS ON BACK 1 Correct Incorrect.. r �/, ] E X A M P 1 L E 1 2 3 <br /> '�v <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />