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,INCWaste Tire ,, ly & Inspection Re oInspection Report Number <br /> , p p .� <br /> 'B@B8" State of California <br /> po:4 CIWMB1811st(New04104) Survey Form - Page 1 3 - 0 .1 3 7 0 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID•- / �-� Inspection Type (Fill one) <br /> Site Suffix: j t/ III <br /> (jD Routine O Re-inspection O Referral O Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �(� {1 sJG+ C kf 01 '0 t, O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name U -"_ --_ <br /> Inspected By Inspector <br /> 7✓ ,A ( � rte <br /> I � I <br /> Physical Address t t p �l <br /> / C. 21 <a <br /> 101 to [AJ I Y-t W v� I ----- ---- <br /> Street F6F/1 <br /> Inspection Date <br /> I <br /> Cify State ZIP Code <br /> , I Time In Time Out <br /> State <br /> Business Rep Title J O AM Eu <br /> O AM <br /> PM ., V a PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count Whole/PTE <br /> (Fill one only) (Fill all that apply) (Fill all that.apply) (Fill all that apply) <br /> �- <br /> ( ) ' f Active ),Passenger (D Generator Outdoor <br /> 0 O Closed 0Altered <br /> GPS Latitude m • O Hauler O Indoor <br /> 0 <br /> O Inactive Truck <br /> Longitude - O Planned �:OTR O End-Use O'Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other <br /> I I <br /> r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> ----- --------- - ---. _ <br /> ST <br /> EQUI <br /> O ' O PRC§42951 AN�MteNireEHauleRr Reg sRatMEN ion dS Transport of Tires O Notice Of Violation O Extension <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§.18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m m <br /> O. O 14 CCR.§18459.1,(a)(b)(c)-Tire Program ID Number from CIWMB I <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 /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> -._... . . —----------- <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred I CIWMB Enforcement <br /> O O 14 CCR§.18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators fd in Compliance - No Violations / <br /> O O Other: § <br /> Commentsl� L/�.. / 'Jill( <br /> ..�. <br /> c <br /> ��.�� �� �, ✓t .(`- _' ' (��� `1✓��k �1crr-J_ G{h?Ir tif � ` tl�i <br /> � <br /> � <br /> o` ; ' I -(. r(,/e0 t� )� l�r �t� GY_i . l!�(� qtr`` ✓ <br /> On t!� t� E _- 0 1/iOiCt�(otrr <br /> Inspection Form Included: Oi <br /> Comments Included: <br /> Business Reps Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: }( i� IEIXI.AIMIP I L1 Z 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />