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Waste Tire SL_ ey & Inspection Report Inspection Report Number <br /> State 1 all(Now Survey Form - Page 1 f $ - 1 0 2 5 8 7 8 <br /> CIWMB 1B1(New nage y <br /> California Integrated Waste Management Board J �J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection p� Inspection Type (Fill one) <br /> 3 Site Suffix: I l-� � D 5 0f Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S(,1UCir�iJtl1� L� LI Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1f/ <br /> 1 Inspected By Inspector <br /> Coal Lti1PFI SC�tcfp j S' rCT- �y <br /> Physical Address <br /> g a C) <br /> Inspection Date <br /> L U CX�t_ C,� � �� ! C1 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply), <br /> I t t 0 <br /> 0 Active 0 Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude — 0 End-Use Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber CC� <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other JC I CQ i�-ttletS jXr4�0 FI b p i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFQRCEMENT.STATUS-_ <br /> .:A HAULING AND MANIFEOT REQUIREMENT-$, <br /> 0 Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle m m <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements L)At13 / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referrat:11/CIWM$ Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ntOtance No Violstionil <br /> ;Other: § <br /> CommentsTreS at roteil ;+V CLv�e' ir'1'D} ✓.0MDye-d .y'oM rlINisa Freet loam— t'-eq <br /> i,9vf-ed -tire I-iv,i,Iev (deCa( :4 0 - oq'_�)�' / hLtttil -�'-2o tiy'e s e0er y Wee k -t, be <br /> Y--i ocied at braciNUn-Tire M&o'i-Fe.S'fis Vi4veef for ktst y-eQt-ae � /���iIt fir " � <br /> - <br /> I <br /> Inspection Form Included: Q <br /> Comments Included: ����i �`'� l�f �'` -`�� <br /> Ausin4p i ature Phone Number n P'ct' <br /> (gnat re Phone Number <br /> INSTRUCTIONS ON BACKlna�drl' ± '� A�i � I II i 2 3 62081 <br /> White Copy:CIWM6 Yellow Copy:Operator Pink Copy:LEA <br />