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Report Number <br /> Waste Tire Suok & Inspection Repo a pection <br /> M � State of California - _ ---— - <br /> Cgrated asteManage Survey Form - Page 1 1 8 - 0 1 3 6 1 0 <br /> California Integrated Waste Management Board <br /> Part A- Suivey BLUE OR BL _ <br /> Inspection Details <br /> - ACK PEN <br /> INK <br /> TPID- ?`.' Inspection Type (Fill one) <br /> Site Suffix r^� <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) \ <br /> Identifier: <br /> Q CHP Q CIWMB Complaint Q Educational Visit Q Other <br /> Business or Facility Name, - <br /> Inspected By Inspector w <br /> Physical Address <br /> ' <br /> Street l l vim` I <br /> x Inspection Date <br /> City Stat Z!/ ode Time In Time Out �•. <br /> Business Rep Title / 0 PM 0 PM <br /> AM AM <br /> - <br /> Operational Status Tire Type Business Role <br /> (Fill one only) (Fill all that apply) (Fill all that apply) r` <br /> ® Active Q Passenger I ® Generator <br /> O Q Closed Q Alteredq <br /> , ? T, <br /> GPS Latitude �'� Q Hauler Q Indo7a�r <br /> C Q Inactive Q Truck <br /> Longitude - U <br /> d <br /> n - se <br /> f; Q Planned Q OTR Q EQ Container <br /> (FIIIII�a r a„ <br /> 0 e Tire Dealer Q Auto Repair 0 Trucking Fleet QGovernment QRetr <br /> eader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer @ Auto Body ,Q Car Dealer Q Collection Q Crumb Rubber I <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 A HAILING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 <br /> 010 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.qp Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirernienis,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 Q 14 CCR§18462-Manifest System Requ ents for Tire Dealers or Waste Tire Generators <br /> Q In Compliance No Violations <br /> Q Q Other: § <br /> Commerks <br /> t17- <br /> OPT <br /> y� a� �'r `/f -r,C 1 .,f ,b�Q i ^u tour e v <br /> :: c t f 7 i��Cef Gy c744 `C <br /> Inspection Form Included: Q <br /> Comments Included: 0:1 <br /> - - <br /> I <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:I. Incorrect: X F;LL '.` A M r" L I I _ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA S <br /> r <br />