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..tM6-? _. .ti .AL iw <br /> Waste Tire Su. ..y & Inspection Report •nspection Report Number <br /> ka <br /> State of California 'J}CWMB Waste <br /> eManag) Survey Form - Page 1 1 1 Q t { <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> nspection Details <br /> TPID- � Inspection Type (Fill one) <br /> Site Suffix: D 5 G7 , S ® Routine Q Re-inspection Q Referral Q Observation <br /> Local "" �-- If Referral,choose referral type(Fill one) <br /> Identifier: .� _ �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ji - <br /> Inspected By Inspector <br /> Physical Address <br /> Street - <br /> -� Inspection Date - F 7- <br /> 1�7 <br /> r�- <br /> Ci y State ZIP Code Time In Time Out_ <br /> Business Rep Title O AM O AM <br /> M m O PM LO PM <br /> Operational Status ire Type Business Role forage Type <br /> Tire Count (Whole/PTE (Fill one only) Fill all that ap (Fill all that apply) ill all that apply) <br /> ® Active Q Passenger Q Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m • Q Hauler Indoor <br /> O Q Inactive Q Truck <br /> Longitude 1 Q Planned JdJOTR lillO End Use Container <br /> EFUNIMM%e (Fill all th <br /> O 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - 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 /> O Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q 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 /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> IF-Al- <br /> 7.A+ r'✓v.v's 1 r 5 a _,' 'r e—I.j t f r L <br /> UL <br /> - - - <br /> Inspection Form Included: Q- <br /> Comments Included: Q <br /> . -- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> X �e� I 62UC1 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: f+. P �. i`. t�2 3� <br /> White Copy:CIWMB Yollow Copy Op+emha Pink Copy:LEA <br />