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r. <br /> �� } Waste Tire Suy & Inspection Report. Inspection Report Number <br /> kall.State of CalifornialWMB Cgrated asteManag) Survey Form - Page 1 1 5 - �10. 06 7California ntegrated Waste Management Board <br /> rt A- Surye BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> — I <br /> TPID- �, I [E] Inspection Type (Fill one)Site Suffix: Fi o It 1 (/'. 1 (-S @ Routine Q Re-inspectioln Q Referral Q Observation <br /> Local �. �/ If Referral,choose referral type(Fill one) <br /> Identifier: �J-f t?, moa (I n t 0uta,, rti O CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name -- <br /> Inspected By Inspector VIII <br /> Jyr� ! 1 _ �j� <br /> Physical Address �� ``f — I {'i� \ Ti i <br /> L )1�COX i41` ! --- - ---- ------ -- <br /> Street <br /> Inspection Date l ( ) D�s <br /> ! ��(:.�C'{�-��.�• t � �� .� I 1. t' <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title AM 0 AM <br /> D �✓ V Q PM / p� V PM <br /> Net / L\4e L(Aft( Alo\-ax" - <br /> r---�� Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) f I L . r I 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> UU �J Active >; i Passenger Q Generator ID Outdoor <br /> D 0 Closed 0.Altered <br /> GPS Latitude m . ® Hauler 0 Indoor <br /> O Q Inactive Truck <br /> Longitude — o Planned OTR (0 End-Use Container <br /> I� <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government C) Retreader 0 Dismantler Q Tire Derived Fuel <br /> a <br /> 0 Used Tire Dealer 0 Auto BodyS 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler Q Agriculture 0 Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -- <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension !, <br /> 0 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O !PR.C§42956-Registration/Decal in Vehicle <br /> O ; O !14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FFI / M / M <br /> O O 114 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> _ . ... .......... _.. <br /> ------ ------- <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q 10 1 Other: <br /> Comments L <br /> i(f� irr ` /( r � Yr . (�e o X( �E` �it'P r adi' <br /> t r <br /> f t'j �(-„�T�l �i1J�t•N.Zt ^�f�� frt+•r'l..ltl' X'L����,'t ��'_�.! :� t � l`_ i,�`i t' \. /f6t�(•'� " i Itltr;I4� f- <br /> J 1 <br /> CI,"tIt ; .. aCi►t � it.rl.l_(-r -/r (= / �._ ^ � " . ,r� LC, <br /> -- <br /> Inspection Form Included Lit <br /> i <br /> Comments Included:0 - <br /> Business Rep's Signature'.-r Phone Number Inspector's S gnature Phone Number <br /> _� W w U � I'� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ) � E, .�,J"dt �' L � 1 � � <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />