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Waste Tire Si ) I S ection Repor Inspection Report Number <br /> State of California I p _ t - <br /> Cgrated asteManan) 5urv� y orm Page 1 1 2 1 0 0 6 6 4 2 <br /> California Integrated Waste Manaaemnnt a.,�.., <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile J Q # Inspection Details _ <br /> TPID- Inspection Type (Fill one) <br /> I - <br /> Site Suffix: ,1 1 <br /> Routine Q Re inspection Q Referral Q Observation <br /> Local ✓ If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWNIB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Inspected By Inspector <br /> o sok <br /> Physical Address - <br /> 26 ArA�' V- <br /> Inspection Date o <br /> / Time In Time Out <br /> Business Rep Title O AM Q AM <br /> -. PM (� 0 PM <br /> 0 � i <br /> -- <br /> - - --� t - --Operational Status Tire Type Business Role Storage Type <br /> Fill ore only) Fill all that apply) <br /> I Fill all that apply) I <br /> A,.;ive Passen er Generator ( PP y) <br /> Tire Count(Whole/PTE) - <br /> f Y lQ gPP Y PP Y) Fill all that a® Q Outdoor <br /> 6 Q C'osed Q Altered <br /> Latitude <br /> GPS Q Hauler ® Indoor <br /> O Q Tractive ® Truck <br /> Longitude Q P'anned Q OTRQ End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Trucking Fleet Q Government Q Retreader Q Dismantler 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 /> -----------.._.----- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> QV ( QA %PR U§NG AN,D MANI aste MANIFESTREQUIREMENTSRQg BREMEN tration and Transport <br /> ransport of Tires ---- -- ---- -------- <br /> Q Notice Of Violation Q Extension <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requ-ements Date Q m / m <br /> Q ® 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> PA <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs witl'n 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> i <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <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 <br /> Q Q Other: § <br /> Comments — <br /> Inspection Form Included: Q <br /> Comments Included: Q 933-31J - --- - - <br /> I usi ss Rep's Signature Phone Number I ctor's Si ure Phone Number-_- <br /> - <br /> 62081 r — <br /> INSTRUCTIONS ON CK Correct ``Incorrect ( X P P <br /> ® ■ <br /> White Copy:COMB Yellow Copy:Operato• Pink Copy LEA <br /> . - 4 <br />