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` Waste Tire SL ey & Ir spection RepOr- Inspection Report Number <br /> .•��� � State of California <br /> Cgrated 1(New <br /> Manag ) Survey Fpri�n - Page 1 11 - 1 0 0 6 5 0 1) <br /> California Integrated Waste Management Board I <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- \ � - O ' Inspection Type (Fill one) <br /> Site Suffix: L <br /> I l (I@ Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral choose referral t Fill one <br /> Identifier: type( ) <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> 0�5i Inspection Date <br /> c ° <br /> e In Time Out . <br /> Business Rep Title Q AM Q AM <br /> Q PM Q 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O ® Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 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 1 <br /> V A HAULING AND MANIFEST REQUIREMENTS O O <br /> Notice Of Violation 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 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EJC <br /> 0 0 14 CCR§ 18459.3- Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> - - --- ------------------------------------ <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: § _I <br /> Comments -..!_ <br /> na 5�b vv' E>n <br /> " o.T Z <br /> 7 Glo`J2- �y �J V4VSA A S't 1 <br /> /tA. > �j OV %AV/N X*- <br /> b� Tt r'e. `7� J� � �NLCOIVLS. LP.nlMM'✓�Civb��D �V�q�(��� �S <br /> .Inspection Form Included: 0 <br /> Comments Included: 0 <br /> 3usiness Rep's S1 <br /> ignature Phone Num}e Ins is Si ,l! .e Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:1, Incorrect: X E XI A P L Er_r1 L <br /> Whee C_-, CIWMB Yellow Copy:Operator Pink Copy:LEA <br />