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4 <br /> Waste Tire Sui .ay & Inspection Report Inspection Report Number <br /> ` ■ It11 State of California 1 ? A A <br /> Cgrated asteManage Survey Form - Page 1 J i u 0 J 0 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / r Inspection Type (Fill one) <br /> Site Suffix: l fi . 3 7 46 d 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: R � >7 L74 O CHP Q CIWMB O Complaint Q Educational Visit Q Other <br /> Business or Facility Nameyo <br /> Inspected By Inspector <br /> Physical Address 3 7 — C- <br /> d� Inspection Date r f7 / 2 / r <br /> Time In Time Out <br /> Business Rep Title () 0 AM AM <br /> C/ � � r� QPM I � � 6 QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) (Fill one only) <br /> ®Active Q Passenger ! Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude _ End-Use Q Container <br /> O Planned OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O 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 O Agriculture Q Shredder ®Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A THAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> O Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB Ffl <br /> O 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> - ---------- -- —---- - <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred I CIWMB Enforcement <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 1 0 1 Other: § <br /> Comments y c °f a-.teAO <br /> 4A 3 7�2-6 <br /> Inspection Form �nc <br /> 7 <br /> ncluded: Q � �/�3 <br /> Comments luded: ® CJ's - " <br /> Business Rep's Sig ature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X) ( 7V I E A X M- p I 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />