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Waste Tire �t �r1S eGtl®rt �� ® _ Inspection Report Number <br /> ® y p p <br /> State of California <br /> Cgrated 1(New <br /> Manage) Survey Form - Page 1 11 - 1127596 <br /> California Integrated Wase Management Board . ....._._.........._..... <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Deta;Oa <br />} TPID- Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re inspection 0 Referral 0 Observation <br /> Local I 'r If Referral,choose referral type(Fill one) <br /> Identifier: (� m �Un 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address ` <br /> i......__...._� <br /> �_IvNc_.........._._...........,....._....._.........._.._..._.__._...__..... _��_......__...._._....._.... Inspection Date F-71-1 � <br /> Lf n <br /> ( t <br /> de Time In Time Out <br /> Business Rep Title �' AM - _.. ... t r.. 0 AM <br /> 0 P I 0 P <br /> 10 <br /> _77 <br /> ......._.. .I�.w. .�....... .... <br /> -.- t Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply)', (Fill all that apply) (gill all that apply) <br /> 0 Active Passengers 0 Generator 0 Outdoor <br /> GP5 Latitude _T ��...°. O 0 Closed D Altered-� (� <br /> Indo <br /> eir•I _ 0 Inactive 0 Truck 0 Hauler <br /> Longitude - I 0 End-Use 0 container <br /> 9 I i 0 Planned 0 01'R <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> -- 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m , m <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 ' 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance No Violations <br /> 0 0 Other: § <br /> Comments <br /> t�'t� o k <br /> Inspection Form Included: () <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector`s Signature Phone Number <br /> ON 6208.1 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: )A `I <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />