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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> Cgrated Waste <br /> eManage) Survey Form - Page 1 1 4 - 1 Q 1 4 8 5 Z <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Llnspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 0 3 f f S d j 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: St,h OCt 4tA + Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name inspected By Inspector <br /> L-12-5 G C_�, �P"e- - 1 <br /> Physical Address j p <br /> Inspection Date O CJ' <br /> GA `5-2-1-F o <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> �<!..,<._r it l r!s h1�,.Q t� <br /> Operational Status, Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 3 (Fill one only) j (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ® Passenger 9 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude i 0 Hauler ' Q Indoor <br /> O Q Inactive • Truck <br /> Longitude - Q Planned Q OTR 0 End-Use 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 Q Other i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS jNotice Of Violation., Q Extens#tltt <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires �I <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Compliance Deadline. <br /> 0 PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements mcoz. <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 0 +14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip logs within 90 days <br /> i (Requfrod_tnrNCV it <br /> Q Q ,14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> i 0 14 CCR§18460.2- Manifest System Requirements for Registered Waste Tire Haulers Ql Referred I dIYIlMB lzitfglteltlttp►ft ? <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 /> rRRr <br /> 0 1 O �Other: § elor.� <br /> (} f ) n <br /> Comments <br /> IF,C_ 1 �f�Pir��C-5 �S L45--J <br /> We,e,.,1 � j LA5" UJ46-h - / auuy UJ2-s 4-- -o r e_.,..ovQ_ <br /> re ;� � ��•�,ie-.- C�Qe.�.t OL- - 0-33 Lf-'7 <br /> Inspection Form Included: Q '�j -�y <br /> Comments Included: � - 4X)7-3�`R6 L �— . /u� <br /> ass Rep's Signature Phone Number qWtor's ignature Phone Number <br /> 62081 <br /> INSTRUCTION ON BACK Correct Int,orrectYX <br /> � 3C A nth P L E T 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />