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Waste Tire Su0jy & Inspection Reportonspection Report Number <br /> ■ =131ISI State of California 7 <br /> CWMB Waste <br /> eManag) Survey Form - Page 1 1 f 1 0 0 5 4 7 L <br /> California Integrated Waste Management Board <br /> Part A- Survey- _ BLUE OR BLACK_ INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ®Routine O Re-inspection Q Referral = O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> N1AA1tc1� <br /> Physical Address' l \ l 1oLStr� 1� <br /> CA Inspection Date O Y 0S <br /> Time InI Time Out <br /> Business Rep Title " O AM Q AM <br /> O PM Q 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 /> ti ® Active O Passenger ® Generator O Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPS O Hauler O Indoor <br /> O Q Inactive ® Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> Q Service Station O Hauler O Agriculture Q Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility FENFORCEMENT STATUS. _— <br /> V? A HAULING AND MANIFEST REQUIREMENTS 1:Q Notice Of Violation Q Extension <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O 40 . 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 (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> -- ----- ----- ----- ----- - ---- <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> 0 Other: § - <br /> Comments <br /> _ `� e ��r - jW t e-f' '� t�'+�- �. �j n 4- `s �-L�—--��u•��_.. c. �,�'_. <br /> - �O1�\'c t ---V''��A -_✓�- _ �1n��V�`�b K C�J__ �('GG��S l� �' � \ d-� - <br /> Inspection Form Included: Q <br /> Comments Included: Q - - -- -- - ---- - � -- - --- - - .. ---- i <br /> - -- - - - - _ <br /> e Phone Number In c (gnat Phone Number <br /> slness Rep's Signature- <br /> INSTRUCTIONS ON BACK [correct:* Incorrect (y,+ �[EXli MIPE 1 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />