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Inspection Report Number <br /> Waste Tire Su -?y & Inspection Report <br /> cs°=� State of California i/'�` Af jJ''�j �f'�j <br /> Califom a'Int Integrated dCWMB,81 Wasteew 04104) <br /> 4ment Board Survey Form - Page 1 1 - 1 Y 1 V 6 5 V <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- l I I 7 C. - Inspection Type (Fill one) <br /> Site Suffix: �j J ' O ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: l rr-tiC f O CHP O CIWMB O Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 ) Inspected By Inspector <br /> Physical Address ✓ C.j ' �} { T -;f C <br /> Street <br /> f .•( ! ;. __ _ r, r- Inspection Date <br /> Cit State ZIP Code Time In _ Time Out <br /> Business Rep Title � O AM O AM <br /> t 0PM � <br /> 1 0 P <br /> {" •li % c Operational Status Tire Type <br /> i Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PT <br /> 9 <br /> ® Active Q Passenger tD Generator O Outdoor <br /> O 0 Closed O Altered <br /> GPS Latitude O Hauler door <br /> O O Inactive O Truck <br /> Longitude - — O Planned O OTR O End-Use Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair Q Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder (J�'Other <br /> .r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire 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 /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / T / 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 or EXT) <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 Sys#em Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O O e : <br /> Comments JFI r r1;J1 'YC,.II / <br /> �Wu Itrt f r t ;� , G�c }Gi'c �� 0 l� <br /> 1')(A Ili O t 1 1 <br /> A" rt G'1j _ 111(,e �t OCCu It�✓tGc� I�tf L-AA Se <br /> v� <br /> �i f rYt t /��k ,+c� ,.�t� u��IUO 11�1Cc,1i��':� S �cp� t3�7- c.�tC . 1►)`tet c t;)r �J <br /> 'I VJ C4t4 1 t} I -P 1)( ✓ <br /> Inspection Form Included: O' - <br /> Comments Included' 1 aw <br /> Business Rep's Signature Phone Number Inn�pector,'s Signature Phone Number <br /> INSTRUCTIONS ON BACK CorrectV Incorrect: X E X A MIPILIE1 111213J <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />