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Y = � Waste Tire SuArvey <br /> ey & In a ion Report Inspection Report Number <br /> State of California (/j <br /> ClWMB 1st(New Manage) F m Page 1 1 9 1006540 <br /> California Integrated Waste Management Board <br /> Part A. Survey__ ----BLUE OR BLACK INK PEN <br /> - - -- - - <br /> Business Profile ns ection Details _ <br /> TPID- nspection Type (Fill one) <br /> Site Suffix: <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local If <br /> Identifier: Referral,choose referral type(Fill one) <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> N � <br /> II Physical Address .,� <br /> -- - -- <br /> 1 s3o Ins DaCA <br /> /1 <br /> Time Out <br /> Business Rep Title ) O AM D Q AM <br /> 4b PM <br /> --- - - - rational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) v (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> 0 Active Q Passenger ! ®Generator Q Outdoor <br /> O O Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O O inactive ® Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantier 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 I* Other <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 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 li PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> FTI / FTI / m <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 (Required for NOV or EXT) <br /> -------------------------- ----------.-- <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> ------------------- <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 Other: § L _ <br /> Comments <br /> �uGtl4 <br /> �'rtica���-�s'-w��-�na�.�C�� 11 ss ��e>o)� _��_ �--1Vv it/�`� • <br /> fig-\�� tom` ��,hn�n '' W 1lso.M �F`��- �tr�__-�o��•z�� v�- �,.•�c-1� �i zs <br /> AI)M V,e W oNnSA 4 r u -tv Nes. <br /> 'Inspection Form Included: Q /r 53 76 <br /> Comments Included: - - - - -- -- <br /> Business P's Signature Phone Number I pec Ignatur Phone Number <br /> INSTRUCTIONS ON BACK rCorrect Incorrect 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />