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"JIWaste Tire Sue* & Inspection Report spection Report Number <br /> ISM State I3 California - - - <br /> Cgrated Waste <br /> eManage) Survey Form - Page 1 )IIII4I <br /> California Integrated Waste Management Board . ' <br /> Part A Survey BLUE OR BLACK INK PEN <br /> Business Profile <br /> TPISite - 7ZR <br /> on Type (Fill one) <br /> Site Suffix: ( <br /> ine 0 Re-inspection 0 Referral 0 Observation <br /> Local - <br /> Identifier: `f t 1 ,,i, If Referral,choose referral type(Fill one) <br /> _ f 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name I - - <br /> Inspected By Inspector <br /> --.-.------- <br /> Physical Addressncl <br /> � � F <br /> Street ��-`�----- <br /> 1 <br /> r <br /> i f -- . . Inspection Date / / T�,] /' ! t� /J <br /> City ! State ZIP Code ' Time In __. Time Out <br /> Q AM <br /> Business Re Fj p Title PMO� [Tj <br /> Q AM <br /> PM <br /> r^ <7^4. Operational Status Tire Type Business Role <br /> The Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply)': (Fill all that apply) <br /> r � <br /> Active 0 Passenger 0 Generator " <br /> w <br /> t , <br /> D • 0 Closed � 0 Altered <br /> GPS Latitude „ <br /> FT� Hauler m <br /> --- -- _ _ D 0 Inactive 0 Truck 0 <br /> Longitude - 0 Planned 0 OTR 0 End-Use <br /> tf y <br /> Business Type (Fill <br /> D <br /> New Tire Dealer 0 Auto Repair Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber - <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> iVl, <br /> A HAULING AND MANIFEST REQUIREMENTS -- <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years - <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments td.fJ.Y r / <br /> � " ,. " �• j I{� 4 ��t �7�� ,,�I�.�-� �� �,.i ! 1. <br /> ( /i7— <br /> (JC i n 1 �` <br /> � .1 'J ✓ 9 -J <br /> Inspection Form Included: 0 - <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector°s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X I.- A It'I 1 i 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA <br />