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= A Waste Tire Sur - zy & Inspection Report Inspection Report Number <br /> �. <br /> Stale of California <br /> -�� <br /> ClWMB Waste <br /> eManag) Survey Form - Page 1 1 3 - 1 0 0 6 5 6 0 <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID_ _ - - - -- -- -- rr -- Inspection Type (Fill one) --Site Suffix: \ ;� b - O outine Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S �� �` t W K Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �k�, <br /> Physical Address <br /> - <br /> Inspection Date CD <br /> c.h <br /> Time In Time Out <br /> Business Rep Title _ ® AMr- e ® AM <br /> 1 (� O PM J 5 " O PM <br /> -- - - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) f S O <br /> ® Active ® Passenger 4 Generator Q Outdoor <br /> - - - - - - - O Q Closed <br /> Q Truck <br /> j <br /> GPS Latitude Q Hauler �Indoor <br /> Q C <br /> O <br /> Longitude - Q Planned Q OTR Q 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 Q Hauler Q Agriculture Q Shredder ® Other CA- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V A HAULING AND MANIFEST REQUIREMENTS T <br /> Q Notice Of Violation Q Extension <br /> Q Q 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 /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 1 Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q li Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for — <br /> Q j Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ( Q Referred 1 CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> I <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> Q Q Other: § - - <br /> Comments <br /> kA C^^^ \A CiL t1 -K-4� <br /> at L <br /> Inspection Form Included::;Q <br /> CommentsIncluded: - -- - -- - - - - - <br /> Q' u ness Re I nature Phone Number Inspector's Signature Phone Number <br /> P 9 <br /> INSTRUCTIONS ON BACK Correct ( correct (�+ E�X A'.lJ� F 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />