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i Waste Tire Sul"& Inspection Reportection Report dumber <br /> B®21 State of California <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 15 - 1 0 1 3 1 2 0 <br /> California Integrated Waste Management Board <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- rr, Inspection Type (Fill one) <br /> I Site Suffix: I LJ7� rci L.'' �� - 101 Q Routine Q Re-inspection Q Referral Q Observation <br /> Local , - If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> j Inspected By Inspector <br /> _r <br /> physical Address 0 <br /> Street Inspection Date <br /> I I Y !� C , i (!A <br /> City U State ZIP Code Time In Time Out <br /> Business Rep Title I O AM O AM <br /> ` I I O PM I 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> f U (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PT". <br /> a Active Q Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use ontainer <br /> Business T <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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VI A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m m <br /> Q 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 for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <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 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments f (')� <br /> -porn Jv r wVIcp Qhd frar►SPor� `'a` QVt yG✓ _ Il��.;ra �'Omclrit <br /> ro(n-15_ V! 6'r,I Q� 70 �►'PiU C o :', /1 . A C I �C _ rt,,-,,— <br /> F'6 I 111 IL) 0 f`0r✓l,"t fwrv1S ObW11 (,oi3iF", j Wan✓ re'I fornq f 51 <br /> Inspection Form _l <br /> c'ude <br /> Comments Included <br /> Business Rep's Signature Phone Number Inspector's Signature - <br /> X Phone Numbe <br /> _ - - <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �/ � XI At h�I PI LI�I I 1I 2 I -3I 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA , <br />