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Waste Tire SL- , ay & Inspection Repor. Inspection Report Number <br /> L 14 StateI --o-f CaliforniaCIWMB 781(New <br /> California Integrated Waste Management Board Survey Form - Page 1 f 3 - 10— Q 6 fi 6 7 <br /> Part A- Survey- BLUE OR BLACK INK-PEN <br /> - <br /> Business Profile Inspection Details -- <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: �o (0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: Say� ,�rJ, czj0,vr 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector t <br /> Physical Address <br /> Inspection Date � (� <br /> LAC- �L <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> l (W PM Z;> ® PM <br /> . usess Role <br /> Operational Status' Tire Type BinStorage Type <br /> Tire Count (Whole/PTE) C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ` ® Active ® Passenger ®Generator ® Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude � Hauler 'I (� Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR ® End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber I <br /> 0 Service Station ® Hauler 0 Agriculture 0 Shredder 0 Other <br /> ------- ----------_.-------- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires f <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 /> 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 x ' <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers C, MB <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities t; 5 q r <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ' <br /> m in Cotnpliahce. o tolabons <br /> 0 0 Other: § - --- <br /> Comments wA 1,�-�— ` ��C�'`'�j t�i- --; <br /> r�-hyJZ <br /> _- <br /> - ^ ` <br /> Inspection Form Included: 0 <br /> Comments Included- 0H `�~- <br /> Business Rep's Signature- -- -Phone Number Ins ector's Signature Phone Number <br /> - - - - --. <br /> INSTRUCTIONS ON BACK Correct IncorrectJE',X AW PIL 1 2 3 62081 <br /> White Copy:CIWMB Yellow Copy Crerator Pink Copy:LEA <br />