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Waste Tire Sur ./ & Inspection Report ispection Report Number <br /> F:Y• <br /> '1IIr..1 State of California i <br /> CWMB grated 7 Waste <br /> Survey Form - Page 1 - Q Q n $ % i <br /> California Integrated Waste Management Board j <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- <br /> Site Suffix: �� _ Inspection Type (Fill one) <br /> L , <br /> Q'Routine Q Re-inspection Q Referral Q Observation <br /> Local <br /> Identifier: «AA � If Referral,choose referral type(Fill one <br /> )S� O CHP Q CIWMB Q Complaint <br /> Q Educational Visit Q OtherBusiness or Facility Name <br /> Isw , \ <br /> _ ) Inspected By Inspector <br /> 'hyslllcallI Address u <br /> Inspection Date <br /> epL'1� z <br /> Business Rep Time In Time Out <br /> Title O AM <br /> _ O AM <br /> `�Zc > Lt�r\-c�V7� � �My�,- / C) 4� 5 C? ® PM 6 'A' ' v 0 PM <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 <br /> ® Active Q Passenger @ Generator ® Outdoor <br /> SPS Latitude O Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> 'usiness Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair # Trucking Fleet Q Government Q Retreader Dismantler 1 <br /> O Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> .rt B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires -- Q Notice Of Violation Q Extension <br /> Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Compliance Deadline <br /> Q PRC§42956-Registration/Decal in Vehicle <br /> O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> 1 O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 1 Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years -------.-.- <br /> i <br /> O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Other: § <br /> ® In Compliance - No Violations <br /> :omments - <br /> (^' <br /> �w•1 tti`5l.�`a^�' �,lrct,� �}�� i7�� - Loci -7 \ S� <br /> A 5 �1 (/ � 11� G� C, <br /> pection Form Included: Q <br /> Comments Included: Q ""✓ ��� �' ��,� <br /> Business e s Si nature <br /> P' 9 Phone Number Al <br /> 4rp3ecrs Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:9 Incorrect: X �. ,ry art P1 Ej V2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® . <br />