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Waste Tire Su. .ey & Inspection Report Inspection Report Number <br /> �- --'K State of California <br /> California CWMB grated 1 Waste <br /> Survey Form - Page 1 t 0 d n Z) t �1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ?? _ _ Inspection Type (Fill one) <br /> Site Suffix: 7 J 8 * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected B Inspector <br /> Physical Address — <br /> Inspection Date 0 <br /> Time In Time Out <br /> Business Rep Title Q O AM 0 AM <br /> 9 PM 0 PM <br /> / 1 ►� 1 Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> v <br /> 0 Active 0 Passenger ® Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude � 0 Hauler 0 Indoor <br /> O 0 Inactive ® 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 ` 2 r �� t✓�S <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS ___--- <br /> V I 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 <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 EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred f 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 Ij In Compliance - No Violations <br /> L0 0 Other: § <br /> Comments ,^�Gp\�'C'�/ ��� Y`L 1�SJ� w y��,� wg ViP��Ce�-� ✓`-��►^ - <br /> CA <br /> 1�1 0 1�I SS�t '�'"I res �✓`�D 1� <br /> VMVA sk tM cA 1 ✓`'fit I v'\ t-Lcora45 �n W 2act� off 5 i he_. <br /> Inspection Form Included: 0 <br /> 76 f S <br /> Comments Included: 0 � - --- <br /> Business Rep's ignature Phone Number I t Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E X A PL 1 2T' <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />