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Waste Tire Sul. - ay & Inspection Report Inspection Report Number <br /> t7L7 State of California5 <br /> California In egrat df81 Waste Management Board Survey Form - Page 1 1 1 10 13 5 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` G C� 5^ O Inspection Type (Fill one) <br /> Site Suffix: ) ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local a If Referral,choose referral type(Fill one) <br /> Identifier: S C\M ,p0. ; (✓p�,�w 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address > - o <br /> Inspection Date � , / '� � � o <br /> Time In Time Out <br /> Business Rep Title O AM _ O AM <br /> C7 Qe PM PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) v (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �- ® Active ®Passenger ® Generator ® Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ® Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> * New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> if 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V PRC 42951 -Waste Tire Hauler Registration a-J Transport of Tires <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 § g p 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Compl. -g with Manifesting Requirements Date FTI <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID'.jmber 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 /> I <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 ® 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® In Compliance - No Violations <br /> 0 0 Other: § - - -- <br /> Comments G ` I ��S -- ��Ct vvI VVINC (�j1n -5 1-� �j�i\( ✓�1� l �V�� (�l i�C�S <br /> -kV\r t\&\-",k�,. ((,c.l � 5 3�-z av <> <br /> ►�L� �por 5 C�v� �[7�� 11 - - <br /> 'Inspection Form Included: 2oq' 4b1U"-{393 V�_4A_ $,/\J,� <br /> Comments Include - <br /> usiness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTION N BACK Correct: Iect: X �,:( F 62081 <br /> ncorr / X A M P; L E; 1 , 2 3 <br /> - _ - -- © S <br /> VI/r,.,=Copy:CIV^lN1B Yellow Copy:Operator Pink Copy:LEA <br />