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Waste Tire Sur**y &"Inspection Report onspection Report Number <br /> -- -- -- <br /> EE ES`` State of California - --- „ <br /> Cgrated Waste <br /> eManage) Survey Form - Page 1 , _ 1 0 p 8 Q 6 6 ,(( <br /> California Integrated Waste Management Board <br /> Part A SurveyBLUE OR BLACK INK PEN <br /> t;,v, <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: - <br /> -.. --- _ � Routine O Re-inspection O Referral O Observation <br /> Local = If Referral,choose referral type(Fill one) <br /> Identifier <br /> O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name — - - - <br /> Insp- <br /> ected By Inspector <br /> Physical Address ffEd 1�F-,, <br /> Street <br /> Inspection Date <br /> City ' State ZIP Code Time In Time Out <br /> Business Rep Title _ <br /> �-1FC <br /> O AM <br /> F <br /> (D PM QPM <br /> JOAM <br /> L� _ + — <br /> 7M1N7711,1,R,9Z Operational Status � ) Business Role <br /> (Fill one only) (Fill all that apply) <br /> OActive <br /> � , Q Generator <br /> GpS Latitude <br /> O O Closed <br /> M <br /> >u �wf O Hauler <br /> — (J) Inactive Irl + , <br /> C <br /> Longitude _ Ot End-Use k , <br /> i <br /> Planned a l O � <br /> �ra�ar r <br /> ����„� ,�;a ,T;til at ;. •, r. y , ,�., r;7�ra M ',. a ,��a�,.'r r r,F �+ t+, , .:�k,, �r ;, <br /> ,�.�ryr <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _1 <br /> : VI A I HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation O Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV orEXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years - - -- - - — -- <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators — <br /> O O Other: § O In Compliance - No Violations <br /> Comments <br /> 1 <br /> r�r� �,� ,�' r 1, _ , ✓�f/ � " — <br /> x, <br /> ,a1'Y �' , M k,��`a � -r P6 � "" rr� a � ,�^� � ""�• a �y,' r �Sw. n �"`. <br /> INSTRUCTIONS ON BACK j Correct:* Incorrect: ( <br /> ■ — _ _ __ © ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />