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Waste Tire Suri. & Ins ection R 4 spection Report Number <br /> p eport p <br /> ®H State of California ■ <br /> Cgrated Waste <br /> eManage) Survey Form - Page 1 1 3 - �1 Q .$ 3-�3 � 4 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Site -Suffix: <br /> S _ Inspection Type (Fill one) <br /> Site tl j( I D % <br /> Routine QRe-inspection QReferral <br /> Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� <br /> &CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P y Inspector <br /> Physical Address - / l <br /> Street <br /> GInspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title )) Q AM 0 AM <br /> r O 4- ' Qi PM m ' m O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q I I I t I f Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> & Active Passenger Generator. @ Outdoor <br /> D Q Closed Q Altered v <br /> GPS Latitude m • �Hauler 1.5 Indoor <br /> 0 Q Inactive @ Truck <br /> Longitude - Q Planned @ OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 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 I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End=Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS (5 Notice Of Violation Q Extension <br /> Q Q I 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 Dater O <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 /> - ---- ----._ ---- ----..-._... <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 <br /> Q Q Other: § Q In Compliance - No Violations <br /> Comments <br /> ...�,�•.-L- h.._(t ,r .'1`r y-c C�. - i tv. i Gf. c', r�U` =� _'�.,.,�_ ' f .-f.. :";!-.�„'T A<:iS 2 9 a <br /> U e[ �- �./�i ��.�r6✓.`�, { 1•�f+_` -•G,. V\ 3- J ? � r/--G-' l:-vT�4 <br /> Inspection Form Included:: <br /> Comments Included:Q <br /> Business Re 's Signature Phone Number Inspector's Signature Phone Number <br /> � <br /> "` a A 1M :� E 1 3 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ) ; <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® S <br /> I _. <br />