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Waste Tire Sufs� & Inspection Reporspection Report Number <br /> State of California <br /> iszu Cgrated Waste <br /> eManag) Survey Form - Page 1 _ 1 4 - 1 Q -1 3 7_1 Aj <br /> California Integrated Waste Management Board — — --_ <br /> Part A. Survey BLUE OR BLACK INK PEN <br /> spection Details <br /> TPID- ) (� // / Inspection Type (Fill one) <br /> Site Suffix: / O J J f j l� r . Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local — ) If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> L_ <br /> Street <br /> rel Inspection Date <br /> `State ZIP Code Time In Time Out <br /> 0 AM <br /> Business Rep Title 0 AM <br /> -� 1 e PM l.' 0 PM <br /> Operational Status Tire Type Business Role Storage Typ <br /> Tire Count (Whole/ <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that ap <br /> ,� d O <br /> ®Active 0 Passenger l Generator 0 Outdoor <br /> O 0Closed 0 Altered ��II <br /> GPS Latitude 0 Hauler 0 Indoo- <br /> t�WT� O 0 Inactive 0 Truck <br /> Longitude - I ' . 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) ' <br /> Q New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other t <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation 0 Extension <br /> - _ - <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 in Compliance - No Violations <br /> 0 0 Other: § <br /> Comments ) - ;,I J�� / 7A I.,., <br /> i pts.l tY1 C f l i?��b' c - C1 <br /> �`f/ti `�` VW�1 'i �l. Jr s n. Y P row I•r(�(�P� } <br /> <J <br /> nUn Tr� - I��C o1�nr . tb1 i5 ✓ieKlet;� . Tri? Fiv�l� rv , <br /> 1 ✓rr { N LS��'1 rl�t-��d n o d 1�! r l ,; (' kl <br /> p ion Form Included: 0 <br /> Comments Included: 0 - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Numbe <br /> INSTRUCTIONS ON BACK Correct: Incorrect: XA�, � :E X A, P L 1 2 F33 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />