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Waste Tire S & Ins Inspection Re Or nspectlon Report Number ■ <br /> Y p p ----- - -p - <br /> State B California . <br /> Cgrated Waste <br /> eManage) Survey Form - Page 1 _ <br /> California Integrated Waste Management Board � ' <br /> 6565 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: / i � <br /> _ 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> O CHP O CIWMB 0Complaint � Educational Visit Q Other <br /> Business or Facility Name -- <br /> inspected By Inspector <br /> r• <br /> Physical Address j - / 1��__ , ,..3 1 ;,�, /'Jvll <br /> OX-1. <br /> Street -- r <br /> i 2 Inspection Date <br /> City State ZIP Cade Time In Time Out <br /> Business Rep Title ��frtT.t/"/' ® AM ^ Q AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type ' <br /> / c? `} (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 --� . O Closed 0Altered <br /> GPS ', 0 Hauler 0 Indoor ' <br /> - O 0 Inactive 0 Truck <br /> Longitude - F�- T� , . ��� 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (F ill all that apply) <br /> 0 New Tire Dealer Q Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer O Auto Body 0 Car Dealer O Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture O Shredder O 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 /> 0 Notice Of Violation 0 Extension <br /> Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> IDI 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 1:11 / <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 /> 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 O In Compliance - No Violations <br /> 0 Other: § <br /> Comments - <br /> Jf'{ 7e-1• �, j Gz�// 44ieor_e, /A_e r:� <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 <br /> 62081 <br /> White <br /> Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />