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® = L ; Waste Tire Su. ay & Inspection Repor .. Inspection Report Number <br /> State of California <br /> Cgrated Waste <br /> Survey Form - Page 1 1 0 - 1 0 0 0 r 0 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A_ Survey _ - - <br /> Business Profile Inspection Details <br /> TPID- a 1 Inspection Type (Fill one) <br /> Site Suffix: t \ 0 ® Routine Q Re-inspection O Referral Q Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier. ' n 0. c� W�).nn O CHP Q CIWMB Q Complaint Q Educational Visit O Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> Physical ABdresWs \ - <br /> 5 L b CA-11 60- Ck Inspection Date <br /> � � z.c�' <br /> Time In Time Out <br /> Business Rep Title O AM _ _ 0 AM <br /> @ PM . <br /> • S 8 PM <br /> -- --- -- - - - -- Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ® Active it ® Passenger ® Generator e Outdoor <br /> O O Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> O II Q Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) - <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V -A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O <br /> 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 /> 0 Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required forNOVorEXn <br /> Q 014 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 HaulerssRe 5 e C IAB r►o ' e <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q © § y q In compliance No olations <br /> 0 Q Other: § <br /> Comments Zti��rt v.,` <br /> �oY_ L:5 I,s, lt_TLS <br /> kq <br /> Inspection Form Included: Q <br /> Comments Included: usness Phone <br /> hone�-Number?2 Inspector'sSignature - l �"-�- `'� �-�$�✓ <br /> Phone Number <br /> �- <br /> :-77-7- 7. -." `'� -` 62081 <br /> INSTRUCTIONS ON BACK Correct Incorrect ( . q X A; P L 12 3 <br /> White Copy;CIWMB Yellow Copy:Operator Pink Copy:LEA <br />