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Waste Tire Su, ay & Inspection Report Inspection Report Number <br /> • rrrCWMB 81California <br /> (teM nage) Survey Form - Page 1171 3 - 1 01 .3. 4 3 2 <br /> CaliforniaiIntegrated Waste Management Board , <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile C IAIN Inspection Details <br /> TPID- J JY <br /> "� �UIrvyQ � Inspection Type (Fill one) <br /> Site Suffix: r 13 1 ' [ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: I+i.l(+1 C Q CHP Q CIWMB Q Complaint Q Educational Visit .Q Other <br /> I <br /> Business or f=acility Name. <br /> /�,, Inspected By � Inspector <br /> Physical d ress <br /> Xg <br /> Street <br /> Inspection Date <br /> -Jd1T�Y'�fi- <br /> Cittate ZIP Code Time In Time Out <br /> Business Rep v Title Q AM Q AM <br /> Apr O O ® PM HI I 0 P <br /> i_`"Tumn rlu _ rerua.�, <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) ;(Fill all that apply) <br /> Tl a Active ® Passenger ® Generator .® Outdoor <br /> CIPS Latitude ITI I # �O Q Closed Q Altered <br /> ` ! J Q Hauler Q Indoor <br /> T-- r. ._ �O Q Inactive ® Truck <br /> Longitude – I I i Q Planned Q OTR Q 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 Titre 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 /> V I A {HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0. 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 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/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 1 Q 1 Other: § <br /> Comments l. <br /> -- - I *'Is C ,`f ha 6110Pvihp vi n o <br /> (WP✓W6"" ho EDr" '�nukes cJigiwed For ✓'efread proees ' <br /> F ,,,Ij_� Ih <br /> Q S .fro _j.t ki C;uSto� . _ fieY c o �'kCkS. <br /> Inspection Form Included: ® 4(k-45SI <br /> "]�p� ��� �6Comments Included: I L!1� r (411 <br /> usiness Rep's Signature Phone Number I pe s Signat Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: ( X A P 1 2 3 62081 <br /> 2J Ah <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> to <br />