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z, Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> rr State of California <br /> ClWMB <br /> 1(Ne w041ge Survey Form - Page 1 1 6 - 10 13 0 9 9 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ^ / inspection Type (Fill one) <br /> Site Suffix: r F� / 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �cZrt I,/ QCHP Q CIWMB Complaint Q Educational Visit Other <br /> Business or Facility Name Inspected By Inspector <br /> dr"Pve/'=� �+��42• �tQ-��� ,per-�..�i <br /> Physical Address 3 9 - O ` ,-'=.��—�J,,, <br /> �a"e — - <br /> Inspection Date / 0 / 2 7 / Q 6, <br /> Time In Time Out <br /> Business Rep TitleAM <br /> ` 0 1 0 AM <br /> 3 0 PM / 2—' 1 ®PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> i Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude _ Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q 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 /> 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 ENFORCEMN,TSTATUS <br /> V A HAULING AND MANIFESTUIREMENTS � <br /> '- Notice Of Violation Q Extension <br /> 0 0 PRC§42951 Waste Tire Hauler Registration and Transport of Tires Q <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date W / / <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMBN11 L <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> `` (Required for NOV or EXT <br /> Q Qrr <br /> 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 i CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities _ ,- <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> Q Q <br /> Other: § <br /> Comments " & 4/ ,p�ean� tI/ Y '7"71 <br /> /� _ d <br /> /�J "e p4,1,e lir" 44_� e;;� Ar-v .� '-,< <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> a x c 62081 <br /> ■ INSTRUCTIONS ON BACKAl44�P L E f <br /> SS'EES ... S v� © ■ <br /> White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA <br /> 6ti3330�.ak174 <br />