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I , <br /> ' aste Tire SuXy y & inspection Report p p ; <br /> lies Inspection Report Number ■ <br /> ■ �•k <br /> 211 <br /> State of California <br />� ? CtWMB grated Waste <br /> eManag) Survey Form Page 1El � 1 :-01 3 2 6 51 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile ,411 <br /> Inspection Details; <br /> TPID <br /> Site <br /> �( <br /> - m Inspection Type (Fill one) <br /> Site Suffix: ? # Routine Q Re-inspection Q Referral Q Observation <br /> Local / ,t If Referral,choose referral type(Fill one) <br /> Identifier: `y i v t(� 0,h 6 ` Q CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business ---or Facility Name -,� J Inspected By Inspector <br /> Physical Address i,{ ` 60r. C <br /> Street <br /> F Inspection Date f� (� <br /> I l <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> { t', <br /> ri*o ilG/ m • m0PM m • m 0PM <br /> � . I <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f I : I I I y <br /> LUUJ LSU ® Active 0 Passenger Generator 0 Outdoor /( <br /> /�. D Q Closed 0 Altered <br /> GPS Latitude m • Q Hauler 0 Indoor ' <br /> O O Inactive p Truck <br /> Longitude — I y I_LO Planned 0 OTR Q.End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ( Trucking Fleet Q Government. 0 Retreader 0 Dismantler, O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Cay Dealer Q Collection Q.Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder 0 Other 1. r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility -ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q PRC§42951`-Waste Tire Hauler Registration and Transport of Tires Q Notice Of. Violation Q Extension <br /> O 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 III / M / El <br /> O O 14 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 /> O O 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 Q Referred/CIWMB Enforcement <br /> O O 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 In Compliance - No Violations <br /> Q 0 Other: § <br /> CommentsCt df/q I✓! '_i��t' i fil 1!�{ r C G�,f{. of 64 <br /> h(a (, lruf(k r)vel -tt(e 2(✓vic( orip-bu Volodoy'r J e*k 1 ter' 161 lav <br /> L ]"iQ <br /> r �_ l .C� f V' u � "' `a to r I _ V n C U.l ( <br /> C (0 r) 0 hcf o PUJ .cKNI ro(r1.I- <br /> nspection Form IncludedI <br /> Comments Included:t - %�(r//- �� - .-: r.� '-� :... Z <br /> Business Reps Signature >� Phone Num "r Inspector's Signature Phone Number <br /> � 1 <br /> �z�_ <br /> INSTRUCTIONS ON BACK Correct:* incorrect: ( ( ��/j A,j�M P t 1' .2 3 62081 <br /> ■ % White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />