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■ Waste Tire S6%4t 8c inspection Repor pection Report'.Number ■ <br /> 7�7t3 State of California <br /> CIWMB <br /> grated Waste <br /> eManage) Survey Form - Page 1 ,� 1 0 1 3 t <br /> California Integrated Waste Management Board -- - - - - -- --- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Ins <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: i ! "> I ��I V 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> -- -J 7I >111 — - <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> Business or Facility Name /";rp,..�, -r r, c c.✓t_y[� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> l <br /> Inspected By Inspector <br /> Physical Address i% / .l.'i f ,a 3•tet <br /> 4 <br /> Street <br /> Inspection Date �f / �F `� / EE6j <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> �� 22 P � 0 PM / =/ 6' 0 PM <br /> Operational Status Tire Type <br /> --' Business Role Storage Type <br /> Fill oneonl Fill all that appl ', (Fill all that apply) (Fill all that apply) <br /> Tire Count (Vyhol15) <br /> ,Active 0 Passenger Generator 0 Outdoor <br /> `` r <br /> O 0 Closed 0 Altered <br /> PS Latitude m • � II� <br /> ��`��� O Inactive 0 1 0 Hauler 0 Indoor <br /> O <br /> Longitude 6 � T 0 Planned 0 OT.,Truck <br /> g 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 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 I0 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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 I 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 /., <br /> f ,,. <br /> Inspection Form Included: 0' <br /> Comments included: 0 <br /> Business Rep's Signature Phone Number Inspector's SignaturePhone Number j <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X I EX�R M '. 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />