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ru_ <br /> Waste Tire Survey & Inspection. Report Inspection Report Number ■ <br /> tr[ State of California <br /> Cgrated asteManage Survey Form - Page 1 F 1 8 - 10 06 3 8 2 <br /> California Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` -I -3 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier_ �G,p� C,Q , Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name f/ //I Inspected By Inspector <br /> L_fiw—cl <br /> Ph Address <br /> Street <br /> Inspection Date <br /> G t"y tate ZIP Code Time In Time Out <br /> Business Rep tGA Title AM 0 AM <br /> Lr O (.�- �� ® PM ' I O PM <br /> �\r.1kQ,-s <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I� ©I O, (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ! ' ®Active Q Passenger ® Generator 4D Outdoor <br /> r r —ll D Q Closed Q Altered <br /> GPS Latitude I , 1 _J Q Hauler Q Indoor <br /> III JJJ Q Inactive ®Truck <br /> D Q Q End-Use Q Container <br /> Longitude , 1 { Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 I ) <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 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 /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities �- <br /> Q ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 40 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments' D� ✓�Cafr-.:'!(F�12�$�`�(��— -t_�(C , •C3 <br /> /)l^4 C '�'�►' -- ��l �5 / -„�,,o,.� 1. G4., r./�Yf�L G3�C <br /> r'N'0S GL✓^7 r NQ (1FrW.�� o,tl�ct�A�L� Tr/Y V�lflC(-✓t, <br /> _I`��(n u�''q-. �_�Z—(--Ili 5f -�v f^�.c1te�.✓ Uro+'^/�e5'r5 1r�1vc'�S. <br /> Inspection Form �nc <br /> ncluded: Q � �5!/!�b <br /> Comments luded: ® - - - <br /> Business s Signature Phone Number gn ,s Sig ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct-70 Incorrect: (� ,� PILI <br /> 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> l <br />