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Inspection Report Number <br /> Waste Tire Su. .ey & Inspection Report:A <br /> State of California I �. <br /> California ClWMB Waste <br /> eManag) Survey Form - Page 1 $ - 1 0 0 O 5) 3 1 <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: ` 3 ti. O l ® Routine O Re-inspection O Referral O Observation <br /> Local t`/ 1 If Referral,choose referral type(Fill one) <br /> Identifier: 41 O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address , `1 ` �.God l abl'e7\�0�+`1� <br /> Inspection Date <br /> L-A %kitl <br /> Time In Time Out <br /> Business Rep Title / 0 AM 0 API <br /> \ 0 ( C7 0 PM 0 PM <br /> v Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> v <br /> Is Active O Passenger 0 Generator O Outdoor <br /> O O Closed O Altered <br /> GPS Latitude O Hauler O Indoor <br /> 0 O Inactive ® Truck <br /> Longitude — O Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agricui:ure O Shredder @ 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 /> - O Notice Of Violation O Extension <br /> O00O PRC§42951 -Waste Tire Hauler Reg stra:ion and Transport of Tires <br /> PRC§42953-Contracts with Reg s'ered'..'aste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal ir `,'eh:e <br /> O O 14 CCR§ 18459 -Responsible En::es Ccmplying with Manifesting Requirements Date m <br /> iO O 14 CCR§ 18459.1 (a)(b) (c)-Tire P-cgra-i ID Number from CIWMB <br /> O O 14 CCR§ 18459.2.1 -Submittal of%lanifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> �,►'�� . ��� `, � W. '. �V� S <br /> Inspection Form Included: O <br /> � <br /> yyL a� <br /> Comments Included: O <br /> Business Rep's Signat re Phone Numb In or` at a Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X �E X 111;rP l_i E1 2 3 62081 <br /> ® White Cc_. C'.'.'.'B Yellow Copy:Operator Pink Copy:LEA © 0 <br />