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Waste Tire SuSay & In �e I ion Report <br /> (� p nspection Report Number <br /> State B California Survey Fo m Page 1 1B - 1006548 <br /> CIWMB 781(New 04104) I' <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE ORBLACKINK PEN <br /> Business Profile spection Details <br /> TPID - l G - O 1 I spection Type (Fill one) <br /> Site Suffix: <br /> 4 Routine Q Re-inspection Q Referral Q Observation <br /> Local Referral,choose referral type(Fill one) <br /> Identifier: <br /> - <br /> _ — �O CHP OCIWMB OCom taint OEducational Visit 0 Other <br /> Business or Facility Name <br /> eQ�'rk 6's, Co-P_ � � 'o� Inspected By Inspector <br /> Physical Address d - O <br /> 1 Inspection Date D / l (� 05 <br /> ` It _C_ ) CA 15 677 <br /> 7 <br /> f Time In Time Out <br /> Business Rep Title AAM AM <br /> Ac-�Q&* OPM <br /> S Y.G(a��� --- <br /> - - - - -Operational Status' Tire Type I Business Role Storage Type <br /> � <br /> Tire Count (Whole/PTE) 7 p <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ®Active ® Passenger ! *Generator Q Outdoor <br /> - -- --- O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all 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 Other �� p A,,kJCo v%, <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ! ENFORCEMENT STATUS <br /> V i q RUNGAND MANI eESTRRQg REMENTS ) O Notice Of Violation Q Extension <br /> OOP §4Hauler sand Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m l <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 114 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance No Violations <br /> Other <br /> O O : § <br /> Comments <br /> G- V/D _ e;,, csf /�t�'�aS oC�� C,ancefvt . f <br /> r-V V T�l�c�- 1^'�a�JI�C� o ^ Vis_ .ce �•'� LAO "e.S <br /> Inspection Form Included: Q' C' <br /> Comments Included: 5�i`�rh✓ `' _�-. � - - / Q <br /> �3.7ieG5_ <br /> Business Rep's Signature Phone iJumber I or's re Phone Number <br /> INSTRUCTIONS ON BACK j Correct:* Incorrect: X XJA*fJLJEJ 1112 3 62081 <br /> - - <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />