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Waste Tire Su#ey & Inspection Reporo Inspection Report Number <br /> Git 6i State B California <br /> Cgrated asteManage Survey Form - Page 1 � _ <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ? , Inspection T e Fill one <br /> Site Suffix: � � r� � �•' � - i p Yp ( ) i <br /> �� I 0 Routine 0 Re-inspection p Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: IV' �. (`,1 CHP CIWMB <br /> P:p tC� rl ' "' 0 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name — -- <br /> +, I Inspected By Inspector <br /> I J L II ,,. It'rtiCiljVe I — <br /> Physical Address <br /> 17 <br /> Street <br /> All I r Inspection Date (� f F <br /> CityI Time In <br /> State ZIP Code Time Out <br /> Business Rep Title O AM 0 AM <br /> �Y ) V ✓ 1.1 PM _ PM <br /> • .J <br /> Operational Status Tire Type Business Role Storage Type 9, <br /> Tire Count(Whole/PTE)_' �� �� . <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude — 0 Closed 0 Altered <br /> GPS m . <br /> O 'I 0 Inactive 0Truck 0 Hauler 0 Indoor <br /> Longitude — FTT-1 <br /> • 7-17—Fi <br /> 0 planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> v <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ! A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires — 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC42956-Re <br /> § iTtetlon/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: § <br /> 0 in Compliance No Violations <br /> Comments <br /> rd <br /> 1� j f <br /> _ I! u, ' G:�t¢''V[.(. e `� 1? `..��';�X ,�s1/r ��� (�f'— YtCj' rf' i. r/�� f`r'y/} i. - N✓t'.(:; ,t4.'/� i"/ <br /> f L) 1-ter f.5 <br /> Jr <br /> Inspection Form Included: 0 <br /> Comments included: 0 -- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X ,;: a +w _ 62081 <br /> White Copy:CIWMB Yellow Copy:Operalor Pink Copy LEA <br />