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Waste Tire Soy & Inspection Report nspection Report Number <br />State of California I <br />kq4XMfo CgraMe ted asteMana a Survey Form - Page 1 _1 4 1010 l 691 <br />California Integrated Waste Management Board _... <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID -Inspection Inspection Type (Fill one) <br />Site Suffix: I 3 y G / (C) Routine 0 Re -inspection 0 Referral 0 Observation <br />Local / _! If Referral, choose referral type (Fill one) <br />Identifier: SVC,< ( /1 i�%lyt•_, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name Inspected By Inspector <br />Physical Address I l - <br />r <br />i; J i f U 0 i>-- <br />( <br />City State ZIP Code <br />Business Rep Title <br />r, <br />Inspection Date + / ? t l F(-, <br />Fj <br />jjTime In j Time Out <br />I�•I —I0 AM [ 1 1•1 0 A <br />Q PM <br />Storage Type <br />(Fill all that apply) <br />Outdoor <br />Indoor <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 <br />V A j HAULING AND MANIFEST REQUIREMENTS <br />0 0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 0 PRC § 42956 - Registration/Decal in Vehicle <br />0 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <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 <br />0 0 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 <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 0 Other: § <br />3 Container <br />e Derived Fuel <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem / m / m <br />(Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />0 In Compliance - No Violations <br />Comments <br />c� <br />7 <br />Inspection Form Included: 0 <br />Comments Included: 0- <br />Business Rep's Signature Phone Number .Inspector's S�gnature Phone Number <br />INSTRUCTIONS ON BACK Correct: 0 Incorrect: X EXTA MI P I L I t: 1 112 3I 62081 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />