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Waste Tire SL ey & inspection Repor ,, Inspection Report Number <br /> State of California <br /> Cgrated asteManage Survey Form - Page 1 1 $ 1 0 2 5 6 3 <br /> California Integrated waste Management Board <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TP1D hh G� n Inspection Type (Fill one) <br /> Site Suffix: V I I ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: r a�, pC�gLtd) 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name �G/� Inspected By Inspector <br /> L ig,id e o T ff iq_s /, } <br /> Physical Address �Q�'t Ft Qt( 1 Z <br /> Inspection Date v Ct I 2 O J 0 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> Q PM O PM <br /> �vn.a'tid� �UYireS DW�PX <br /> Operational Status Tire Type Business Rote Storage Type <br /> Tire Count(Whole/PTE) D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O o Closed 0 Altered <br /> GPS Latitude o Hauler 0 Indoor <br /> O 0 Inactive o Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use f 0 Container <br /> Business Type (Fill all that apply) <br /> (a New Tire Dealer 10 Auto Repair 0 Trucking Fleet 0 Government o Retreader 0 Disfnantler o Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body o Car Realer 0 Collection 0 Crumb Rubber <br /> o Service Station o Hauler 0 Agriculture o Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ,ENFORCEMENT STATUS <br /> V HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Vloletion , 0 Ext4A�tEt�it ' <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 o PRC§42953-Contracts with Registered Waste Tire Haulers. coin <br /> ppBpCe AeedlJns <br /> 0 0 :PRC§42956-Registration/Decal in Vehicle y I <br /> 14 CCR 18459 -Responsible Entities Complyingwith Manifesting Requirements <br /> e uirements Date0 0 m tm( <br /> I- <br /> rX <br /> "`' <br /> 0 0 14 CCR§18459.1 (a) b c Tire Program ID Number from CIWMB I <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (ReguhedforN4V9t�- %✓' <br /> 0 1 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 I Q lieferred r CIWMI>� >I ,?f1en$ <br /> i ifs u <br /> -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 114 CCR§ 18461 <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other: § <br /> /�^ �y, d1 <br /> Comments-Vlsr.1` fd t`aC{,-r�i / Ar ojast-e --hr � Y"wJ all -or-es, �oy� cz-t <br /> t; ins cfi�n r c� <br /> `max i <br /> ✓'ack ecf l s�► td by 5�2z�� y r�r a� wiav+.i F sfs � - -te fi✓r <br /> k, Lurej b� ►-t, �45te 1,,,Je,-- —1(a Tz Ahste lVe s <br /> �ct+tIec fWD W2e.�_s . /Qfl VfD1a_H6kVS d,F <br /> Inspection Form Included: 0' <br /> Comments Included: 0 �� 4tt7�' J t2j f'w <br /> Business Reps Signature Phone Number Insp tor's Si n tuie Phone Number <br /> INSTRUCB"tIRN BACK Correct:* Incorrect: X (*' J X A M F S E 1 3 62081 <br /> KB White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />