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Waste Tire Sup y & Inspection Report inspection Report Number <br /> State B California <br /> of arc Cgrated Waste <br /> eManage) Survey Form - Page 1 1 3 . 1 0 1 0 ( 6 8 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> -. ection Details <br /> TPID- f /� Inspection Type (Fill one) <br /> Site Suffix: / `/ CJ 1 - ( Routine Q Re-inspection Q Referral Q Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> / <br /> Identifier: ( .f�l.[jra,� , Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ✓ <br /> Inspected By Inspector <br /> Physical AddressJ t q f <br /> l _ `� i <br /> Street l l <br /> J t i Inspection Date <br /> State ZIP Code Time In Time Out <br /> Business Rep J Title O AM Q AM <br /> !b` + l !J t r Gt.,ct V- <br /> C <br /> • m 0 PM • m 0 PM <br /> Operational Status Tire Type Business Roletoiage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count Whole/PTE , <br /> ,.,(• . ,„•.,. ) L Q Active Q Passenger (6 Generator Q Outdoor <br /> GPS <br /> Latitude m D Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O 0 Inactive Q Truck <br /> Longitude - Q Planned Q OT LoEnd-Use Q Container <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 /> i r <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I l "j f�4((.`/( it <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 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 Date M / 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/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q i 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> Q <br /> Q Other: § <br /> Comments {jib ` ( ont h4lt Ar <br /> �r <br /> t CAGh nh h tu S UUCcsh tc­ to r(f.'rtct tri+rt G7hC= /,� ...� j✓') .{ JpvlCF' <br /> _. ( c U c( tA K6(” 6 J/:LYIC <br /> IC4 ,-X- k, Icy ;/P�C�,-) <br /> Inspection Form Incl u ed: Q <br /> Comments Included: Q - -,- - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X i E xI A ,M Picj[; 1 3 62081 <br /> White Copy:CIWMB Pink Copy:LEA <br />