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■ "� Waste Tire Suy & Inspeciion Repo In1p,ection Report Number. . ; <br />SIM <br />State <br />iw a 811fornia(New04104) -Survey Form' - Paae - .10 8 8 3 6 6 <br />California Integrated Waste Management Board <br />J �./ <br />Paft A'- SurveyBLUE OR BLACK INK PEN <br />Business Profile i Inspection Details <br />TPID -Inspection Type (Fill one) \ <br />Site Suffix: 1 Sr( v Q Routine Q Re -inspection Q Referral Q Observation <br />Local <br />Identifier: <br />i y <br />��{'1 �Zt G4 rte• f <br />If Referral, h se.referral type (Fill one) <br />Q CHP Q CIWMB `Q Complaint Q Educational Visit Q Other <br />Business or Facility Name ' _ <br />I l t • / ( �RJ� �,1 �, rC � <br />� <br />Inspected By <br />—� — <br />Inspector <br />-- <br />Ph <br />Physical Address" <br />v <br />)VA V t <br />%r SC <br />l 6'� v +,� <br />Street <br />Inspection <br />Date <br />City State ZIP Code <br />Business Rep Title[K�] <br />Time In <br />O AMO <br />Time Out <br />AM <br />lty�c <br />1FcC' <br />C� (a PM <br />[dj L� ® PM <br />Tire CountWhole/PTE <br />( ) <br />_ <br />Operational Status <br />(Fill one only) <br />Tire Type <br />(Fill all that apply) <br />Business Role <br />(Fill all that apply) <br />Storage Type <br />(Fill all that apply) <br />§ Active <br />Q Passenger <br />Q Generator <br />(3 Outdoor <br />-- <br />I Q Closed <br />Q Altered <br />Latitude <br />GPS <br />m <br />• <br />❑O <br />Q Hauler <br />Q Indoor <br />Q Inactive <br />Q Truck <br />Longitude — <br />1=0 <br />Q Planned <br />Q OTR <br />O End Use <br />Q Container <br />Business Type (Fill all that apply) <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 I 1 <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility ENFORCEMENT STATUS <br />V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br />O O PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q O I PRC § 42953 - Contracts with Registered Waste Tire Haulers. Compliance Deadline <br />Q Q PRC § 42956 - Registration/Decal in Vehicle <br />Q O 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements Date <br />M/M/m <br />Q Q 14 CCR § 18459.1 -Tire Program ID Number from CIWMB <br />Q O 14 CCR .§ 18459.2.1 - Submittal of Comprehensive Trip Logs within. 90 days (Required for NOV or EXT) <br />O O 114 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />O O • 14 CCR § 18460.2, --Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br />O i O 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O 0 ', 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />& In Compliance - No Violations <br />Comments f iJ <br />l 1 r , f �� r f c i IrU_f� C y� <br />-� { C L. _ �i - tIf J. <br />f <br />l"{� ' .),( Iry t ; '� 1'� t/)�F [. r l�.i rl l t ✓"F' �� (,+1' { ; f/ y/� f ii L�. <br />LCiF"'lC �syr�—_ (^1Utkjl i1.1`1;�(o: J"''!rF f .�rt.t '2r <br />)1A <br />Inspection Form Included: O' L CIS <br />Comments Included:5ss, - <br />Buslnesis Rep's Signature Phone Number Inspect is Signature Phone Number <br />INSTRUCTIONS BACK Correct:I* Incorrect: ,_) y E X .A;M P ,� E 2 3 62081 <br />■ - _ -- r ® ■ <br />' White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />