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i = Ay 8c <br /> Waste Tire SL . Inspection Repor. Inspection Report Number <br /> z. <br /> State California Survey Form - Page 1 i 8 - 1006572 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> PartA- Survey BLUE OR BLACK IN PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Z t7 l7 ®Routine Q Re-inspection Q Referral - = Q Observation <br /> Local /' If Referral,choose referral type(Fill one) <br /> Identifier: �rM� -0 Gz CoJ'� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �i Physical Address <br /> \� \ \�w�5�oc'co��cr. L _ <br /> Inspection Date G� 5 <br /> Time In Time Out <br /> Business Rep • `` - - Title 0 AM 0 AM <br /> L t►°l�t�' /`� S s'eQ'¢f V�S� (� 'Z - ® PM J �- 5 PM <br /> r <br /> - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) l (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) - <br /> Q New Tire Dealer Q Auto Repair ® 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> Q Q I HAULING AND PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> V A MANIFEST REQUIREMENTS <br /> Q Q 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 m / m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q j 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 ye <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 ® In Compliance - No Violations <br /> Q 1 Q Other: § <br /> Comments <br /> � _ L. <br /> - <br /> 'Inspection Form Included: Q <br /> 6' t7 <br /> Comments Included: <br /> B -- - - - - - - -- <br /> siness Rep' gnature Phone Number Al Spector's S gnature Phone Number <br /> INSTRUCTIONS ON BACK Colrrr�-/ 62081 <br /> f . t )ncorrect L i r✓ E X A{hh P L E 1112 3 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />