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Li Al Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> X11 State of California <br /> gratedW 1teManag) survey Form - Page 1 1 9 - 1 0 1 4 7 7 4 <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: 1 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local �. If Referral,choose referral type(Fill one) <br /> Identifier. C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name [ Inspected By Inspector <br /> Physical Address <br /> 161 ­70,; <br /> f Inspection Date <br /> � .t✓l, GA �'S 23( 3 <br /> Titne In Time Out <br /> Business Rep Title Q AM Q AM <br /> O PM O PM <br /> 5!-� <br /> T ' <br /> Operational Status I Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) !(Fill one only) i (Fill all that apply)i (Fill all that apply) (Fill all that apply) <br /> f ®Active Q Passenger t®Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q Now Tire Dealer Q Auto Repair e Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer U Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATg4 <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation.. I!»xtertsian <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires , <br /> I 1 <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date I I. <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number frau CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOYoC' <br /> Q <br /> Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMEi EttftiEit@fF# 6 <br /> ij <br /> O Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q ® 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ! i <br /> Q Q j Other: § <br /> Comments ? f <br /> rS LAC,4 +re.'e ever/ ; k-�,. <br /> VJa9 c- —cS►-� w�s;,�;- s-l�/ -�or- ek)�y tvH/.��v1�I )-� �„� +e,jL,\$�.J br- <br /> I.12c .P - -ti�,tErS �hcQ p —4-91 (1,...�h;-t�'ST" cz>ry c#-&�G -1za— <br /> e�r�. �ol X — P, mac- h,•�r•fss- —� /z; <br /> Inspection Form Included: Q <br /> Comments Included: Qqnt, <br /> ne ep Signature Phone Numbers s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect_ ( �/� E X A P t 3 s2oa1 <br /> ■ L © ■ <br /> While Copy:CIWMII Yellow Copy:Operator Pink Copy:LEA <br />