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■ koCIWMB181 <br /> Waste Tire Sur y & Inspection .ReportInspection Report Number <br /> State of CaliforniagratedsteManage) Survey Form. - Page 1 - fl 132 ' <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile <. Inspection Details <br /> - r1 r Inspection Type (Fill one) <br /> Site Suffix: 91 <br /> ( <br /> Site ffitel ' <br /> J `�' ' @'Routine. O Re-inspection Referral O Observation <br /> Local r f If Referral,choose referral type(Fill one) <br /> Identifier: l,)r <br /> �� Q CHP Q CIWMB 0 Complaint 0 Educational Visit Q Other <br /> Business orff��Facility Name - t Inspected By Inspector <br /> Physical f� Address( �r ��;ir f I r/ <br /> t <br /> Street I <br /> C71 <br /> J �, � Inspection Date f j f /�({ t:: J t t F ( u <br /> City State Zlp Code Time In Time Out <br /> Business RepC/ Title Fo AM Q AM <br /> .- • ]0 PM m ' m 0PM <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 /> Q Active Passenger Q Generator 0.Outdoor <br /> Closed 0 Alt <br /> C @ Closered <br /> GPS Latitude m • Q Hauler 0 Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - O Planned :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 0 Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture . Q Shredder (D Other <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 Notice Of Violation 0 Extension <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires i <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline , <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 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 E)(T) <br /> _..._.... <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip.Logs for 3 years ------- --- <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O 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 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> t) ` ~1 r� } ! .aiAJF.j4.! �^lC•''I/�t ffyi <br /> r 1� f f)L�' ;.,./ .�t../ j , tlJ (i _ic.- "/.'.i.• t /r • , 2 . <br /> tt <br /> «'!'G? `t � r. +"ts�(. <br /> ( ✓ `(l -7 p <br /> t <br /> nspection Form Included 0 <br /> Comments Included �' _� '- -.. -.. ------ - ..Business Re 's Signature Phone Number Inspector's Signature Phone Number <br /> -r 62081 <br /> INSTRUCTIONS ON BACK Correct:� Incorrect: ) � �; .�4� MP I,L I Ej It, 23 . <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA. ® ■ <br />