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Inspection Report Number <br /> Waste Tire Su, y & Inspection Report <br /> State of California <br /> CJWMB grated asteMana 41 Survey Form - Page 1 11 - 1 0 1 4 7 4 2 <br /> California Integrated waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile l Inspection Details <br /> TPID- f Inspection Type (Fill one) <br /> Site Suffix: 3 ! g — I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �,, If Referral,choose referral type(Fill one) <br /> Identifier: J vQ vi' O CHP Q CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> I <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM _ O AM <br /> ' 0 P 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> j Tire Count (Whole/PTE) + f ,� �, w (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply) <br /> v 0 Active ® Passenger ®Generator 0 Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude O Hauler O Indoor <br /> O O Inactive Q Truck <br /> Longitude — O Planned O OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer O Auto Repair O Trucking Fleet Q Government O Retreader Q Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> Q Service Station 0 Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ,ENFORCEMENT STATUS <br /> I <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation �} FJ(ts}1lgEt <br /> r <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 Q PRC§42956-Registration/Decal in Vehicle m <br /> Q Q 14 CCR§ 18459 - Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (RBqulrt9d.farNOV OrQC?j ; <br /> Q 14 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 Haulers Q Ro%rred f DI111FMB @111 f4m )A <br /> Q Q j 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities s i�ry <br /> .. <br /> O O <br /> 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Gfllhplllt>EtSt Nit V p ' <br /> Other: § - �: <br /> _ 1 1 !! 1 <br /> Comments <br /> L_�e;e_ -PI-0 1:� ( 33 lG�sz-o1 ow ���S+s_ <br /> Inspection Form Included: <br /> Comments Included: 0 <br /> Buslne Rep's Signature ,one Number n ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK f Correct: Incorrect: ( ( j ,� p E f 62081 <br /> White Copy:CIWM6 Yellow Copy:Operator Pink Copy:LEA <br />