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t,t14 <br /> vita: to Tire SL,._ yy & In-spe�ction Report. .4,spection Repori Number <br /> �� Stag:of California <br /> CI"rated a'stJeManag j Survey Form - Page 1 r 3 - 1 0 7 9 3 9 0 <br /> California Integrated Waste Management Board <br /> Pari A- Sutvey BLUE_ OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / -7 Inspection Type (Fill one) <br /> Site Suffix: / g D 0 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 <br /> Inspected By Inspector <br /> S'f v e,1G1-o.r d1i j'S'c �^/U.>g 7;9&9 i4 <br /> Physical Address 3 / - �l/.3 /3,V 1-4-1/ <br /> 3077 �-�cr �u=tea" Z-► /1 <br /> Q� o2 Inspection Date <br /> Time In Time Out <br /> Business Rep Title �,J ^ ® AMAM <br /> O PM L <br /> O PM <br /> - <br /> �J Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 6 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS _ _ 0 Notice Of Violation ; O Extension' <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> I <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> I <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred 1 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 ® In Compliance - No Violations <br /> 0 0 Other: - <br /> Comments <br /> Inspection Form Included: <br /> Comments Included: 0 — - <br /> usiness Reps Sig ature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I I X I A IM I p L E f 62081 <br /> White op . I MB Yellow Copy:Operator Pink Copy:LEA <br />