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Waste Tire Sur\,,dy & Inspection Report nspection Report Number <br /> 1 StateCalifornia Survey Form Page 1 1 3 - 1 0 2 5 8 7 3 <br /> CIWMB 1B1 thew 04104) <br /> California IntegratededWaste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> fBusiness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` 0 7 2, 7 0 O Routine ® Re inspection O Referral O Observation <br /> Local ` �� If Referral,choose referral type(Fill one) <br /> Identifier: � � — O D O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name {i•--- B Inspected Ins Inspector <br /> ! � p Y <br /> Physica dd're ss <br /> �n inspection Date 0 -3 I 7 C1 <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> C_. r 0 PM 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 /> • Active O Passenger ® Generator O Outdoor <br /> O O Closed O Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O O Inactive ® Truck <br /> Longitude – O Planned ® OTR O End-Use OP Container <br /> I <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> ®Used Tire Dealer O Auto Body O Car Dealer O Collection 0 Crumb Rubber <br /> O Service Station 0 Hauler O Agriculture O Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENTSTATUS <br /> V111: A' HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle m m <br /> O O ' 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements pate <br /> O O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB L L I I 1 <br /> O O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV orEXT) <br /> 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> ! <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers ( Rsforri !CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ;In CQrlpll8nce No Violations_ _ _ <br /> O I O Other: ,/j ,��7 <br /> Comments / /�lY►1 '�✓ '�" 15i - l 6 -�ti <br /> Go �- res ��5`� } C��'-1 <br /> t_1 4-3 j-f �- y ,-- o ��;� w c� /� t ,�;rs .•a�,,sok , <br /> Inspection Form Included: O " ��J ��25K6 <br /> Comments included: O _• <br /> sines,Rep's Signature Phone Number In s Slgna a Phone Number <br /> INSTRUCTIONS ON BACK CArrt�ct` Inporr ct� �^! �"�' v) L�W7; �����; �_��L �1_� to 62os1 <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA K <br />