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=I Waste Tire Survey & Inspection Report Inspection Report Number <br /> esa. <br /> $tate of MB18tllomia Survey Form..- Page 1 I - 1 Q 1 0 8 3 2 <br /> CIWMB 181 stew nage - Y g <br /> Calltomia Integrated Waste Management Board "�' <br /> PartA-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / u 9 / Inspection Type (Fill one) <br /> Site Suffix: <br /> le Routine O Re-inspection O Referral O Observation <br /> Local• n If Referral,choose referral type(Fill one) <br /> Identifier: Sall 04 G[u�r O CHP O CIWMB O Complaint 0 Educational Visit Q Other <br /> Business or Facility Name a _ <br /> ,,� L� J fC / /K� I Inspected By Inspector � <br /> Physic Addr s R LDa <br /> S!" <br /> Street <br /> Inspection Date <br /> 9 <br /> City�(p State ZIP Code Time In Time Out <br /> Business Rep Title : O AM O AM <br /> O PM QPM <br /> (� Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) t t (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> IS Active O Passenger ®Generator O Outdoor <br /> 0] O Closed O Altered <br /> GPS Latitude m. � OHauler Olndoor <br /> O Inactive O Truck <br /> Longitude - O Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder ®Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STA_T__US <br /> V A HAULING AND MANIFEST REQUIREMENTS O 011Of Violation O EM� <br /> xtension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days - (Required!or NOV or EXT) <br /> O O -- - <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O 13007etl 1 CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In C mpliance - No Violations <br /> 1010 Other: § <br /> Comments <br /> k41 4ee Ire - <br /> 60GyeWTj <br /> go <br /> e - <br /> Inspection Form Included:O <br /> Comments Included:0 — <br /> Business Rep's SignAure7:�Ihone Number Inspector's Signature Phone Number <br /> � <br /> INSTRUCTIONS ON BACK C.orre-ct:� In.eorrec hb X a P L E; 1 Z 3 62081 <br /> ■ 07284040243 White Copy CIWMB Yellow Copy:Operator Pink Copy.LEA ® S <br />