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Waste Tire Som & Inspection Repo r spection Report Number <br /> L6State of California <br /> ClWMB 181 04104) <br /> California Integrated Waste e <br /> Management Board Survey Form - Page 1 1 4 - 1 0 0 0 4 5 3 <br /> PartA- S_urvey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / C/ q / Inspection Type (Fill one) <br /> Site Suffix: ! �' 3 C� / Z�4 ( ® Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: CJc�N C�y fit^ ���y LriD Q CHP O CIWMB O Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> /�, <br /> PhysicaYAddress <br /> S <br /> -7 oq <br /> Inspection Date / :2— / a <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> O PM Q PM <br /> Operational Status Tire Type. Business Role Storage Type <br /> Tire Count(Whole/PTE) / 0 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ® Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O O Inactive O Truck <br /> Longitude – Q Planned O OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair O Trucking Fleet O Government O Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer O Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> O Service Station O Hauler Q Agriculture Q Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> Ego=1211111111111 <br /> PRC 42951 Waste Tire Notice Of Violation 0 Extension <br /> § - ire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> i <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred l CIWMB Enforcement <br /> 0 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> ® O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 10 1 N�;H �ot3tiQff� <br /> O Other: § <br /> Comments <br /> i r�5 <br /> Inspection Form Included: Q <br /> Comments Included: Q � 00 <br /> dthiness Rep's Signature Phone Number ctor's S g at �fe�Z Phone Number <br /> INSTRUCTIONS ON ACK A I R 1 '2 3 62081 <br /> ite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />