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Waste Tire Survey & Inspection Report. . ,Inspection.Report Number: <br /> ifr State of CaliforniaIWMB fill(New g4/e4) Survey Form -..Page�1 �... 1014 0.--5 8 8 . <br /> California Integrated Waste Management Board <br /> Part A-Surve : BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' 1� Inspection Type (Fill one) <br /> Site <br /> Site Suffix: / ^ ®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 VInspected By Inspector <br /> L ✓m o _,M a k4zQ ACer-�Ji cle _ <br /> Pysical Address q E�� <br /> Street <br /> AMCA <br /> City � //V�,(� Q—state a3�ZIP Code Inspection Dale I o � � l FO / <br /> Gi /� -� I Time In Time Out <br /> —]0/� <br /> Business Rep Title O AM O AM <br /> -- Operational Status Tire Type Business Role Storage Type <br /> I� � (Fill one only) (Fill all that apply) (Fill.all,that'apply) (Fill all.that apply) <br /> Tire Count(Whole/PTE)'U r <br /> LLL it.Active Q Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m. Q Hauler Q Indoor <br /> 00 Inactive ®.Truck <br /> Longitude Q End-Use Q Container . <br /> - - - -.- . ..-- - - -Q_P..lanned- _ .Q OTR - - <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 <br /> I <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> --- - <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 <br /> Q Q 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 EXTJ <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§1846012-Manifest System Requirements for Registered Waste Tire Haulers Q Referred!CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste-Tire End-Use Facilities <br /> .14 CCR§18.462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> �In Com Iiance - No Violations <br /> 0 . 0 <br /> Comments ©a-1, ,L _.�� e 7 ac /`G <br /> �ri a w 1��JW1�6`j rip s CitL FZ�` 9VSieswt 4f4i_s <br /> V_ fr a,✓' ( tr <br /> C ora _S a s /1 , 0 0i <br /> Inspection Form Included:Q �{ q rn <br /> Comments Included:® 4�9 <br /> - - —+ <br /> Business Rep's Signature Pone Number Inspector ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct. Incorrect: Wt X A P •L E �, :2 3 szosl <br /> ■ WhileCopy:CIWMB ' Yellow Copy:Operator Pink Copy LEA - <br />