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"= Waste Tire Suet& .Inspection Repor Inspection Report Number ■ <br /> NIS <br /> State ofCalifornia - <br /> State f 81fornia 104) Survey Form - Page 1 - 0 2 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ mInspection Type (Fill one) <br /> Site Suffix: (a Routine Q Re-inspection Referral Q Observation <br /> Local /1 t If Referral,choose referral type(Fill on ) <br /> Identifier: ��t L_ ptt 0 t.t n`t Q CHP Q CIWMB Q Complain Q Educational Visit Q Oth6 <br /> Business or Facility Name Inspected By Inpector <br /> Physical Address ,� C11 11 <br /> — I I Y�"t t s, �•, t Z <br /> Street <br /> Cate <br /> � Inspection D <br /> C C � r �15� �( <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> ] / <br /> IE : 0 PM m � 0 P <br /> I II I <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) a y (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f U ))Active Passenger (a Generator Outdoor <br /> Latitude m C O Closed Q Altered <br /> GPS Q Hauler Qi Indoor <br /> O <br /> ED0 Inactive O Truck <br /> Longitude — Q Planned Q OTR O End-Use 0,Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader @ 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 IvM�� I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A i HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q. O 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 /> On 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> O -` 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retxati6n of Manifest Forms and Tire Trip Logs-for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referr'ed/CIWMB Enforcement <br /> Q 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 <br /> Q In Compliance - No Violations <br /> Q O Other: § <br /> Comments . <br /> tr I, <br /> .• �I ,,I, �i <br /> '". t y --ire ,• v r:, --�^•—r— t <br /> i �� (• , � .J Ir,Ilr.r1 � IVln�r ; <br /> Inspection Form Included: O' r( <br /> O , p `� r ; <br /> Comments Included: ' <br /> Business Reps Signature Phone Number/ Ins ector s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: (X)(� E •AMP' L� 1 . .� 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />