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Wase Tire Sulk & Inspection Report ispection Report Number <br /> State of California . <br /> CIWMB181 <br /> Waste <br /> eManag) Survey Form - Page 1 1 0 1 0 0 6 6 9 6 <br /> California Integrated Waste Management Board <br /> Part A- Survey IBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Z h ( � I r 0 Routine 0 Re-inspection 0 Referral (0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: t t ( I 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Namej <br /> .�r('�• Inspected By Inspector <br /> Physical Address 3 <br /> dq � I 1 <br /> Inspection Date / � <br /> State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> Q PM � I I QPM <br /> r '� I Operational Status Tire Type Business Role to rage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) all that apply) <br /> I i 111 11,11 11 <br /> Tire Count (Whole/PT <br /> Active Passenger Generator utdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude — I 0 Planned (0 OTR, 0 <br /> End-use Container <br /> Business T all that app'iy <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet ® Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 /> I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 Complying with Manifesting Requirements Date M / M / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number 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 I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 4 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments —" + f <br /> l_ `L'Y ._ — � 6-�' '+:7 r" � -�r"� -'�..._� � � ..,tail.:"`�'-�" •l..)�' �t.- '�7Y`... 7 <br /> i <br /> t; 1 �7 <br /> _ _ ---------...----- <br /> Inspection Form Included <br /> � Comments Included: 0 c <br /> � ,Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X i E X i,A, ?-+,i P L I E I 11 12 13 I 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />