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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CWMB ,stdeManage) Survey Form - Page 1 1 6 . 1 0 0 6 61 3 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- q Inspection Type (Fill one) <br /> Site Suffix: / ! r Q Routine ®Re-inspection Q Referral Q Observation <br /> Local Of Referral,choose referral type(Fill one) <br /> Identifier: D Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (y Inspected By Inspector <br /> Physical Address r.y4, c�L/GtlS: <br /> 550 C-7 <br /> Inspection Date © / 0 g I c) <br /> Time In Time Out <br /> Business Rep / Title 0 AM 0 AM <br /> a1/ Jr eP e-y— O PM 0 PM <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 /> f ®Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude ® 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 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 ® Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEM. NT STATUS <br /> V 4 A. i HAULING[4ND MANIFEST REQUIREMENT'S Q Notice Of flolatlon 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 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 (Req red for NOV or EXT) <br /> 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 CIWM8 Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _- <br /> i <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In CompI1 once No Violations <br /> Q Q Other: § I <br /> Comments fZYl�ilnX�7$ �t�GhT1G�— (S JcVL7� �j �— se- <br /> — <br /> Inspection Form Included: Q <br /> Comments Included: q� <br /> Q Business Rep's Signature Phone Number 1 oris Signature Phone Number <br /> INSTRUCTIONS ON BACK �Oprrect' corre.0# y ; L._ .r�_ 1p :►�1 ::_l:j�:C-.I 52081 <br /> Entered White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> KS <br />