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Yy�!te Tire Suroy & Inspection ReportInspectlon Report Number <br /> iS ifornia <br /> ! �r CIWMB grated Waste <br /> eManag) Survey Form - Page 1 ��` 6. 3 <br /> ' California Integrated Waste Management Board ,. _ _. - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> ; Y w 1 r7zt rr a gin <br /> 'M N..,. r„ir rrr.r..:;� �' .�,....*,ti�ru p s ,;, „ , M.. r T. :�%tea �t'��>:;:, . ,.,, •rrr---r•*;rp.r T <br /> rl fr a- b,r tJ ,Aad,. rw• w' ,:, ,5� a nd!.r,r"l'Irq„ t,,F, „, i, ;r ", N.,:;tr' /r d, • �: s- — a r vs t-,,, <br /> :,,re�,,.y --�. <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: "7 . <br /> (g) Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral t <br /> Identifier: ""rte 'r type(Fill one) <br /> QCHP QCIWMB QCom Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 1,, <br /> Physical Address – <br /> 11 f.._ _ � <br /> Street J <br /> f, Inspection Date <br /> ulty <br /> — State ZIP Code Time <br /> In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> r If 0 PM � ' m Q PM <br /> L I - <br /> Operational Status Business Role <br /> ( x i iia <br /> (Fill one only) (Fill all that apply) <br /> � 1r�tf <br /> Active M:A y�, <br /> ! Q ( Generator Ctltc1f <br /> Latitude -10 Q COSed Q. at aAA �. (r 6r iso avrau'ti r� l <br /> Q Hauler <br /> GPS ��ntl� lfrNrr arr# <br /> O <br /> Q Inactive <br /> Longitude End Use <br /> Q Planned Q <br /> 3teslness Type (1-ill ail that applY�' <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 1 <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 1 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years — - -- ------ <br /> 0 <br /> - -- --" -- <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § In Compliance - No Violations <br /> Comments <br /> r , <br /> * Fri <br /> x <br /> i........... ... r`.a.fx <br /> INSTRUCTIONS ON BACK Correct:* Incorrect. 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />