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Waste Tire Sur, _y & Inspection Report Inspection Report Number L <br /> State of California �' <br /> CaliforniaCWMB grated 1 Waste <br /> Survey Form - Page 1 i - 1 0 u n ( 2 0 <br /> fornia 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: C> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �C\,V- ,�,ZG1," ,� �\��„� Q CHP Q CIWMB Q Compla Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> ` C <br /> /, - q Inspection Date V (� > Ci <br /> Time In Time Out <br /> Business Rep Title ® AM -/ O AM <br /> + } 0 P lr V @PM <br /> �kAOperational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) `S -57 (Fill one only) (Fill all that apply) i Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger J_� Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q End Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q D z—antler 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-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 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 EXE <br /> ------------------- <br /> Q Q — --- <br /> 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 r� In Compliance - No Violations <br /> Q Other: § <br /> Q - <br /> Comments ` <br /> �..e C." <br /> `���r7 , Lu5 �„c�71.� ,,rt ►-t, �,.�CL b l�l o`� �L�Z \ ►v�S <br /> Inspection Form Included: Q <br /> Comments Included: Q r `, Oll <br /> B sines,Re s ignature hone Number I spector's SAgYtre� Phone Number <br /> -r----- ---� � 62081 <br /> INSTRUCTIONS ON BACK orrect: Incorrect: X (� E X A h4 P lam;F 12 <br /> White Copy CIWMB Yellow Copy.Operator Pink Copy LEA LA ■ <br />