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..M. Waste Tire S�ey & Inspection Repor , inspection Report Number <br /> nia <br /> 06 Cgrated1 asteManage) survey Form - Page 1 1 7 - 1 0 2 5 8 7 7 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> i <br /> TPID- 22 /� Inspection Type (Fill one) }} <br /> Site Suffix: _"7 rT � $ � � � I ® Routine Q Re-inspection Q FCe�� <br /> Local If Referral,choose referral type(Fill one) <br /> E UPY <br /> Identifier: j f� C��O jQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J <br /> Inspected By Inspector <br /> Physical Address 3 I { (L411 •��it <br /> � Va ftO415e61 �f. <br /> `l 5; O J Inspection Date <br /> 1_0 & t N <br /> Time In Time Out <br /> Business Rep f� Title q O AM O AM <br /> O PM O PM <br /> ad�Sti�� J Y <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) ' (Fill all that apply) <br /> *, ee t� Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> o 0 Inactive Q Truck <br /> Longitude — O End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Deafer ® Auto Repair Q Trucking Fleet Q Government Q Relreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 'Other �( I UtNtrt(ftJ�,ur <br /> Part B- inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility g !!I;EMENT:STATUS .. . , <br /> I '';A MAULING]tNDM1N1FE$T RECtJIREFAEIVTS Q iptice Of Violation Q Extension <br /> Q Q PRC§42959 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Comps ice:Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle m <br /> Q Q 14 CCR§18459 - Responsible Entities Complying with Manifesting Requirements Date [T]Q O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) ^ <br /> Q O i 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years f <br /> Q O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Roferi'vd!CtWM9- Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q • O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Ift•£gtttplletr4c� • No lltofattalis , <br /> O • 0Other: § _ J -- -- -- - -- ----- <br /> Comments paC1,I i� 11 o+ 98G�2•t' <br /> .J � was}2, ftr�e s cal 44S t w1e At .fu's S i6✓2_ <br /> &+Ij <br /> Mis-f"�j <br /> Oyj,i�4;L• Maws ' eas -41e erQrayls( S. _ <br /> .Inspection Form Included: Q[ / j <br /> Comments Included; �r�9 /Yr�" 1✓ t"" <br /> Business ignature Phone Number r I ector' Ignature Phone Number <br /> INSTRUCTIONS ON BACK Cgt'I'ib r1i11'tl .�/1 i _ Lill PIL1E �ty� 62089 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA <br />