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Waste Tire SL ;ey & Inspection Repor Inspection Report Number <br /> State of California <br /> CIWMB 187( ege) Survey Form - Page 1 1 8 - 1 0 2 5 6 4 7 <br /> California Integrated WasttManage <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> ' TPID_ ` � � � � � � r � I Inspection Type (Fill one) <br /> Site Suffix: } I® Routine Q Re-inspection Q Referral Q Observation <br /> Local ' /� if Referral,choose referral type(Fill one) <br /> Identifier: Sari �O(��A Q�V't �^ !OCHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 'Ilr l/ v Inspected By Inspector <br /> Ac, Coy TrUct, Tr'e Svc. �. .Lnc, <br /> Physical Addr ss — i Q Z_ <br /> 9`3 <br /> Inspection Date Q z � I <br /> Time In I Time Out <br /> Business Rep Title O AM Q AM <br /> Q PM O PM <br /> �Q;l ship Fafeman <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) /, +(Fil)one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f !� ® Active Q Passenger 0 Generator Q Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPS - Indoor <br /> Q Inactive Truck 0 Hauler j <br /> o <br /> Longitude — Q Planned Q OTR End-Use Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government • Retreader Q Dismantler Q Tire Derived Fuel f <br /> Q Used Tire Dealer Q Auto Body 0 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 /> V' A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q <br /> i0 Notice Of Violation Q Itittpttifolt <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§ 18459,1 (a)(b)(c)-Tire Program ID Number from CIWMB L <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> (Required for NQV or SX fj <br /> Q O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years - "-" <br /> O Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB 1566r41em0� <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities 'y <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators F ice;s y <br /> in-.rCQmpifattic N@flif� �; <br /> O ® Other: § <br /> CommentsVT on I115fechoK .'jW0 'ice�U 5 G�P��1 tiBr' -�ireS f0/" re'{,^ WF7>'GI YttA SfS <br /> an0� fir. I p9s , Waste 'flue ii' a4AZFzStS far +last-e fire S �act,�e 4u' j ttQ'D <br /> htipn,�'�t s well"'e moved' Arta of oontm,: 18kuo."), 1 -- k"efazh eoirieS. VP <br /> a,U ma4j�ests at Fart li* _f r -vW retread fires on s'ite- <br /> lnspection Form Included: 4ufitne_ssRep'S <br /> S,sli `' <br /> Comments Included: ignature Phone Number pector ignature Phone Number <br /> ' - 62081 <br /> INSTRI�%ON BACK Correct:0 Incorrect: E X A M P !. E 12 3 <br /> KB <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA <br />