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Waste Tire SL _ ey & Inspection Report, Inspection Report Number <br /> CIWMBCalifornia <br /> ti(N w04fo4) Survey Form - Page 1 f 7 - 10 0 6 7 2 0 <br /> California Integrated Waste Management Board <br /> Part A- Survey_-_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- q 2Inspection Type (Fill one) <br /> Site Suffix: \ J J l 0 Routine Q Re-inspection Q Referral - Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: S 0.ti�0�, vUu04 L'W Q CHP 0 CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - - - <br /> Inspected By Inspector <br /> Physical Address - <br /> '� <br /> , <br /> l� ( �, _ Inspection Date DI ( �t p 7 <br /> \- ` 0%V � Time In ` Time Outl <br /> Business Rep Title _ O AM /� 0 AM <br /> A PM 'c © (p PM <br /> tA <br /> - - - Operational Status 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 /> K ® Active Q Passenger Generator Q Outdoor <br /> O O <br /> GPS Latitude Inactive Truck 0 Hauler Indoor <br /> Closed Altered <br /> 0 <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply)-- <br /> 0 New Tire Dealer Q Auto Repair ®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 Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ;ENFORCEMENT STATUS _ <br /> - ---- --- ---- - —---- --— —--—-—- ---- ----- - - � <br /> V F A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> 0 0 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 Q PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 - —(Required for NOV or <br /> Q 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years f <br /> Q QQ Referred I CIWMB Enforcement <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q 0 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 <br /> In Compliance No Violations <br /> Q Q Other: § <br /> --- -- - -- --- - ---- <br /> Comments Un.t 5 w ` /� V e� �� L U S <br /> Inspection Form Included: Q �G h� I I C� <br /> -�3L5 <br /> Comments Included: QIdin <br /> 4s '_ <br /> Ign re Phone Number Insector's Signature Phone Number <br /> — 62081 <br /> INSTRUCTIONS ON BACK [Correct:_ Incorrect_ , E'x A M P 1 L E 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />