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Waste Tire Suy & Inspection Report Inspection Report Number <br /> Stateof <br /> 04104) <br /> CIWWMBMB1181(New Survey Form - Page 1 1 2 - 1 0 13 Q 5 1 <br /> _ <br /> California Integrated Waste Management Board — <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I 4 I �( I t LoL .., <br /> Q <br /> 1 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ( 1 (cl ({.ty 11 (: t•/' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address j — f �) 1 , J{ <br /> Jvi i . <br /> I Street _, � <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0AMO PM OO PM <br /> u I <br /> Operational Status Tire Type Business Role 6 Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1% Active Q Passenger Q Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude m Q Hauler Q Indoor <br /> _ 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> (a New Tire Dealer Q Auto Repair Q Trucking FleetGovernment Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Co ction Q Crumb Rubber <br /> Q Service Station ® Hauler Q Agriculture Q Shredder\ Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and Etd-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS _ Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 Date Fp / m / M <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 I 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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments �. i�,L �G� WO - l l � <br /> t,a,� f� _fltP` ✓;4`it"! � t `��f ��T�t 1/fF�' If-rt i17�� <br /> ( <br /> r Vt�Ir (.��,1 icy I �r 0t 1 :��1 i -f t�i ixO , Y F' (eod <br /> � �( .� � ICU► 1 Ct I � •�►,�- ,-,.� } .,/�-- ;.,( i-.� i rt �.,�„1�� �� ��'��... <br /> Inspection Form Included: Q <br /> Comments Included: O <br /> Business Rep's Signature Phone Number Inspector's Signature,_ Phone Number <br /> X �n�111 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � � X A, M P L � � C 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />