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u <br /> Waste Tire SL*y & Inspection Repor Inspection Report Number <br /> -a;'[2 State of California Jit{ I/� <br /> Cgrated 1(teManage) Survey Form - Page 1 1 8 - 1 01 3 V 0 L <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: / „� 7 oz Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> - <br /> Physical Address r a <br /> /// y/ /// / I J v�, i✓,�T,� i iL'�� I <br /> Street <br /> Inspection Date <br /> �,� w <br /> CiN State ZIP Code I' Time In Time Out <br /> Business Rep TitleFFF01 <br /> 0 AM ) ,( Q AM <br /> r / 0 PM / Cl 0 PM <br /> Operational Status rtire Type Business Role torage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) Fill all that apply) <br /> Tire Count (Whole/PTE /' <br /> (a Active 0 Passenger (3 Generator Outdoor <br /> O II Closed 0 Altered <br /> GPS Latitude 0 Hauler door <br /> 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use ntainer <br /> YP pp <br /> Business T e III ata ly) ' <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body ® Car Dealer 0 Collection 0 Crumb Rubber <br /> ® Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> PartB - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> _ <br /> A 'HAULING AND MANIFEST REQUIREMENTS <br /> O0 Notice Of Violation 0 Extension <br /> 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 <br /> 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/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § - - -- -- - — <br /> Comments f <br /> /�,,.�,, ; r s-y�'� r�,,,ir>� rt'f ✓! ''��-&'^d � t�j, ,�%<';1-c.-G.c��-�_ f`�� j`:, ,, r�_4�, . "y .,� <br /> Inspection Form Included: <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X '�' \/ IE X A P L 2 3 62081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />