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Waste Tire Su �y & Inspection Repor .. Inspection Report Number <br /> •��ii- State of California - <br /> cgrited f(teMaage) Survey Form - Page 1 17 1 0 0 6 5 0 6 <br /> California Inlet'ruled Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � � - � � Inspection Type (Fill one) <br /> Site suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �--• If Referral,choose referral type(Fill one) <br /> Identifier: C� irh�! Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> � .LLJJ <br /> Business or Facility Name Inspected By Inspector <br /> steaI <br /> Address <br /> 66z- <br /> ,z, 12LC ✓r [[l 111 s <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> 0 P 0 P <br /> Operational Status I Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply) <br /> ®Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude Q Planned Q OTR- <br /> g Q End Use Q Container <br /> Lon <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENF.ORCEM_ NT-STATUS <br /> V ' A i HAULING ND 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 i Q PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 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 (Req red for NOV or EXT) <br /> Q O 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 if. IWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q ® 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compll inoe No Violations <br /> Q Q Other: § <br /> Comments •�'"". �1�;ti GP� ��! C'777�� _,/yON7•�Tj�. (I�"y � fir.^ ��- �fl".' - <br /> 1 <br /> rad-- �►-- i,.�+�^�-�' s�- 1�v33r4 -00169-7 5—R <br /> Rre- v Ctj, ct�,r►-/� �fL�2 110.6 Cr 4--r -4k, —rP i D )d 9 2-639 r v 1" <br /> Inspection Form Included: Q, <br /> Comments included: Q <br /> Busines p's Signature Phone Number ctor's Signature Phone Number <br /> t 62081 <br /> INSTRUCTIQNB,q�BAC Correct* Incorrec#: �(i-�. \I ��� +� Wl�� l I(._ <br /> Ent <br /> KS <br /> E 1tKS White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />