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_ Inspection Report Number <br /> Waste Tire Sus ay & Inspection Report <br /> 51173 State of California <br /> �r Cgrated 1(teManage) Survey Form - Page 1 i 6 - 1 0 0 6 6 3 7 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACKINK_PEN <br /> Business Profile Inspection Details - - <br /> i TPID- Inspection Type (Fill one) <br /> Site Suffix: l 7- I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ? Inspected By Inspector <br /> Physical A d e s t C7 J \ <br /> 50 <br /> Inspection Date V 6 O <br /> Time In Time Out <br /> Business Re <br /> `Title �...� �� / / *AM J 4 Q AM <br /> - 1 O PM , / - (----- - @1 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 /> T <br /> f V • Active ® Passenger Q Generator Q Outdoor <br /> O Q Closed 0 Altered <br /> Latitude <br /> GPS ®Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned ® OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q 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 0 Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EX7) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> •�xrtd � Ss` r <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Refe,r�r6d 1 CIWMB+`Eh orcements, <br /> I� <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® In Complianceiodations ,. <br /> 0 0 'Other: § - <br /> -----------\----- `,�,-.- (� \ <br /> Comments � ` � --•-'�-� �� �\����5 _ ���s^�- - <br /> Olt�. <br /> Inspection Form Included: Q. _ <br /> Comments Included: 77,161 <br /> BusinesoepW'sSignature Phone Number Inspect Phone Number <br /> '- 62081 <br /> INSTRUCTIONS ON BACK Correct:' �ncorrect (�iLL`"` E iX AA P L E 12 3 <br /> White Ccz�y.CIWMB Yellow Copy:Operator` Pink Copy:LEA <br />