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Waste Tire Su l& inspection ReportO'spection Report Number <br /> _ _ <br /> ifornia <br /> State B 811(tNew <br /> Manageme Survey Form - Page 1 [ x 1 0 1 3 1 8 3 <br /> California Inte rated Waste Mana ement Board _.. - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile ` Inspection Details <br /> TPID. I `"L_1. � � Inspection Type (Fill one) <br /> Site Suffix: J ( ! Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: >; r. y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L <br /> Inspected By Inspector <br /> Physical Address <br /> 1:6T7_N /1 <br /> i i <br /> 5treet <br /> Inspection Date <br /> K]7 <br /> CidState ZIP Code Time In Time Out <br /> ' <br /> Business Rep Title AM Q AM <br /> � • �' 0PM �� • C_ QPM <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 /> r Q Active Q Passenger 'I Q Generator Q Outdoor <br /> GPS Latitude m • —� j o ®Closed Q Altered Q O <br /> I Hauler Indoor <br /> _D Q Inactive QTruck <br /> Longitude — i T <br /> Q Planned Q OTR Q End-Use Q Container <br /> .gym„.,m. <br /> s ,a <br /> Q New Tire Dealer Q Auto Repair Q 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 /> V A j HAULING AND MANIFEST REQUIREMENTS <br /> - 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/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 Q In Compliance - No Violations <br /> Q Q Other: § ----- <br /> Comments <br /> Inspection Form Included: <br /> p- Q' <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X rev �4 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />