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iiia== WasteeaTire Su ey & Inspection Report Inspection Report Number <br /> State of Californi <br /> CIWMB181 <br /> Waste <br /> eManage) Survey Form - Page 1 t 9 _ 10016Z,381 <br /> California Integrated Waste Management Board <br /> Part A- Survey -- - BLUE OR BLACK INK PEN <br /> Business Profile -- - <br /> Inspection Details - J <br /> TPID- - -Site Suffix: C7 _ Inspection Type (Fill one) <br /> - �- � � � ` <br /> Local <br /> - - _ - - 0 Routine Q Re-inspection Q Referral Q Observation <br /> � <br /> — <br /> Identifier: <br /> If Referral,choose referral type(Fill one) <br /> S 0.� R c �� Q <br /> f tt""lam Q CHP Q CIWMB <br /> Business or Facility Name Q Complaint Q Educational Visit Q Other <br /> -- - -- -- - - - - <br /> Inspected By Inspector <br /> �Physical Address \ 3 G► <br /> < a L � .---�r/ Inspection Date 4 o <br /> Business Rep Title Time Out <br /> Time In <br /> 0 Z O AM Q AM <br /> GXCk Pte\ �ot,e J\ , �w / ® PM fl0 PM <br /> -- - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)!i <br /> f ' <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude 0 Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> I - <br /> Business Type (Fill all that apply) - -- -- <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 A HAULING AND MANIFEST REQUIREMENTS T — - <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension i <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 1 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 r {I2egd�retl f�rNOVorEX7 <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Log:for 3 vel <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> �Q�f.e 'erre CIWMB Enforcement �p�°. <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 - <br /> Q Q-Other: § <br /> In Compliance - No Violations <br /> Comments- _-- -_-_.--- <br /> cm,IV <br /> r. -L o 3— <br /> L CLk- <br /> S Q,evv'-- W-�-S- �S1 5- bpi 1 ox, <br /> Inspection Form Included: Q �- ^ <br /> Comments Included: Q - V v <br /> ss p s Ignature Pho e N mber Inspector's Signature Phone Number <br /> �.- _r 62081 <br /> INSTRUCTIONS ON BACK `Correct Incorrect ( � E'X A'M p L El I 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA FI-A <br />