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lspection Report Number <br /> Waste Tire Su" .y & Inspection Report <br /> State of California <br /> Survey Form - Page 1 i 2 - 1006668 <br /> California <br /> CIWMB 181(New nage y <br /> California Integrated Waste Management Board J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 (2 l i Ci Q Routine ® Re-inspec-1 Q Referral Q Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: ��� ��� v, l,p �y4V Q CHP Q CIWMB Q C:�-iplaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address > — G 1 > c �'t- Cc't �c'G( <br /> L1 i Inspection Date ;` C � V <br /> Time In Time Out <br /> Business Re Title� Q -a%l O AM <br /> 5-q Z- ,%1 0 @) PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all tha:apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passe-iger ® Generator Outdoor <br /> Q Closed Q Altere <br /> GPS Latitude - Q Hauler Q Indoor <br /> O Q Inactive ® Tru-_k <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <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 (a) 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations . <br /> Q Q Other: § <br /> Comments <br /> u�'- -���v. ��rtvL '� <br /> o� \ S � �(��ci5 �S <br /> � ; <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X "�k V E L E 11 2 3 <br /> White Copy CIWMB Yellow Copy:Oper.rdor Pink Copt -= <br />