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iiWaste Tire.S y & Inspection Repo pJ pection Report Number.•/CVrate asteof Ma4age Survey Form - Page 1 ') � 1 �1 0 1 3 � 9-5 <br /> California Integrated Waste Management Board <br /> Part A. Su, ey BLUE OR BLACK-INK PEN <br /> Business Profile Inspection Details <br /> TPID- (� VJ�� - [E], <br /> Inspection Type (FillonesSite Suffix: (1 (6/Routine 0 Re-inspection 0 Referral Q Observation <br /> f' <br /> IdentifierLocal : Fs� <br /> If Referral,choose referral type(Fill one)`y, <br /> � �. <br /> h t e ( i ( LA J— Q CHP Q CIWMB Q Complaint Q`Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> I r lei -"1 ✓ 1 ri C_ <br /> Physical Address , �'� - l �) r {dim o, <br /> Street <br /> 4-Y Inspection Date <br /> _erode -10k) � o� <br /> City State ZIP C de Time In Time Out <br /> Business,Rep Title m • m O0 AM 0 AM <br /> PM m • m O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) = Jrid <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that aPPIY) <br /> t t0 Active !o- Passenger (t).Generator b Outdoor <br /> TO Q Closed � Altered <br /> GPS Latitude Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned OTR End-Use Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government (z) Retreader Q Dismantler Q Tire Derived Fuel <br /> (C) Used Tird Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> l Q Service Station (5 Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> _.._.... - _ -- —.. . ............. <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> '-- -- Q Notice Of Violation Q Extension <br /> Q <br /> 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 I 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 /> ► (Din Compliance = No Violations <br /> Q Q Other: § <br /> Comments o 1 1! ,1 l 1 I / / <br /> C, o �t �t�J1Ub1� yIo(a t (c, 1 � bt ll� t7�Pi1 (�I�CiV ed, ACIIIItT f <br /> ADT` �i0ol �I C �F�YCL)Ll(, r �t r c �<< / (✓ � , NO 1 <br /> V10 (A C. 0r 6✓00 ( cry <br /> Inspection Form Included Q <br /> Q(/ <br /> I <br /> Comments Included QI �. - . . .----- - <br />'t ';Business Rep's Signature Phone Number lns ector's Signature Phone Number <br /> ,/ 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ��! .A��IA P L. 11122 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © . <br />