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Inspection Report Number <br /> Waste Tire Survey & Inspection Report ■ <br /> rra. <br /> rli state of California <br /> CIWMB 181lNewtl4fO4) Survey Form - Page 1 1 6 ­ 10134 <br /> 9 2 <br /> California Integrated Waste Management Board BLUE O K INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details 11, 64 <br /> TPID- InspectionType (Fillone) vvvvv <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ZL/T O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date !! <br /> s�Ouc.,,&O,, Qs'-"zos`, <br /> City State ZIP Code Time In Time Out <br /> Business Rep TitleM-09 <br /> AM <br /> S"c� p PM l d V (� O PM <br /> �- -- — - Operational Status Tire Type Business Role Storage Type <br /> I i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) : f <br /> •Active Q Passenger Q Generator Q Outdoor <br /> .0 Q Closed Q Altered <br /> GPS Latitude l 0 Hauler Q Indoor <br /> L- ' --' Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> . I <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 I I <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 • 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 Q14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days — (Required for NOV or FACT) <br /> Q O 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 I CIWMB Enforcement <br /> Q Q 14 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 /> Q Q Other: § <br /> Comments Ze.� �` l J Cf1 sa✓tzc/ af-f ce [( L!/ s[a k oel <br /> Inspection Form Included: Q <br /> Comments Included: <br /> usin s Rep's Signature Phone Number Inspector's Signature Phone Number <br /> �-�/ 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: (� �J EX A M P L E 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />