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Waste Tire Su y & Inspection Report Inspection Report Number <br /> = State of California I - .� <br /> CIWMB 181(New <br /> Manag ) Survey Form - Page 1 a 1 0 u 0 ! 1 0 <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: 7j �.. �. ll `j G <br /> ®'Routine 0 Re-inspection 0 Refers! 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S u , �G.G�„c l.k ���t 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name r Inspected B <br /> P Y Inspector <br /> Physical AddressC-w�L <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0AM <br /> Q AM <br /> _ - CU Z v � O PM U � �1 _� ® PM <br /> 4,Ir-4-_S <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 /> > > 4 v G ® Active 0 Passenger .® Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> G�7S Latitude � 0 Haute, ® 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 ®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 <br /> ------------ <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 /> —� <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 orEX7) <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 /> ----------------- -- - -- -- -- <br /> 0 # 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> 0 0 Other: <br /> Comments <br /> 012c t vv-4-1, .z l �; w j, <br /> > t�nr•�(. ��_2,,,,�, �c t—c f <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Insp ctor s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ,a j,�,' —�_! 62081 <br /> ® White Copy CIVVi Yellow Copy:Operator Pink Copy LEA <br />