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08W73040184 <br /> Waste Tire Survey <br /> & Inspection Report Inspection eport Number ■ <br /> It State of California `r� <br /> CMIMB1 asteMnage - Survey Form - Pagel � � 1 V - 1- 0 1 0. 8 3 6 <br /> Caliromia Integrated waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / � � 02 � � � - � Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sem_ d/Q � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical AddressK� / I /�Fx,y�yc y <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> m ' m0PM m 'm 0P <br /> O J"•s' _ Operational Status Tire Type Business Role Storage Type <br /> � Tire Count(WholelPTE) �- (Fill one only) (Fill all that aPPIY) (Fill all that appy,) (Fill all that apply) <br /> � 0 Active ®Outdoor <br /> l <br /> 0 Passenger (&Generator <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> (� D Q Inactive 40 Truck <br /> Longitude - I I I 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 /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V <br /> =HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 <br /> Q tQ 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 (Requirod for NOV or E�T) <br /> Q Q <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!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 <br /> Q.Q�� +ter[ � �41�N61r�c n'� Q.�co� G!/f�r�•B+� V <br /> /7.r�..oye l�lfGr�c �%'�. ,Cts%s l�i'ew�.< ct�o,•, /���_ �j�i <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> BusinessRep Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081 <br /> EXAhhP '� �� 123 <br /> . White Copy:CIWMB Yellow Copy,Operator Pink Copy:LEA ® ■ <br />