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Li E . <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> Cgrated 1steManage Survey Form - Page 1 1 3 - 1 0 <br /> California Integrated Waste Management Board <br /> Part A--Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q r,, Jf Inspection Type (Fill one) <br /> Site Suffix: I O $ CJ W f j IID Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local n If Referral,choose referral type(Fill one) <br /> Identifier: S0A joe l i V, 1 +ot' �j 0 CHP 0 CIWMB 0 Complaint Q Educational Visit 0 Other <br /> Business or Facility Name (� ill <br /> Inspected By Inspector <br /> If-e wi-ff- hpme ..- .s2-vim <br /> Physical Address Cl I <br /> 9 ZS S _e bwad o S+ <br /> S.W*� ^ q5�0� Inspection Date I Z / S <br /> (`�'' Time In Time Out l <br /> Business Rep d � Ti�tlle�r O AM O AM <br /> ./�1' O PM O PM <br /> Operational Status! Tire TypeBusiness Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) l (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ® Passenger ®Generator Outdoor <br /> i <br /> Latitude O 0 Closed 0 Altered <br /> GPS 0 Hauler 0 indoor <br /> O 0 Inactive le Truck <br /> Longitude – 0 Planned OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 Now Tire Dealer ` Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantier 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility E�NFORCEMENT'STATt1 : <br /> V HAULING AND MANIFEST REQUIREMENTS 0 Notice of Violation 0.Extenak+n <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 /> (RegUired lar NS91lgr:: '} i <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days l <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 l 0 Refal'rgd{CIIW�IA!# 6f1f¢rt�tltfl�� y <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 /> tri, lrtpl ' Nti <br /> Il �tlt��,f'�1 <br /> 0 0 Other: § <br /> Comments i`­ixC't try is ctA CLKID r'erc it 5kop u.iqtk does not oto -+Lree <br /> -wr v i Ce • <br /> by Brah n rin 7.re Sery i c_A�-, red tiS�C-� haLj-'-,- <br /> Fa e� 1►`+ d,o.es notVAer &e- used +iy-es <br /> Inspection Form Included: 0 ,(,(,t�_ (���( QC] <br /> Comments Included: 0 tm 9 . I� 33 - _ f 3-/ ` <br /> s ep's Signature Phone Number In actor's i elute Phone Number <br /> WSTRUETQNGS BACK Correct:* Incorrect: t", ( } �/ E x p f t r 62081 <br /> t -- - - __ - ----- © ■ <br /> KB White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />