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Waste TireSu & Inspection Report ,pection Report Number <br /> State of California - <br /> _f;� ; <br /> CIWNIB Waste <br /> na0ge Survey Form - Page 1 i 02 - 1 G G 6 n 6 0 <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: �l, <br /> 1 1 ` , ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> Q CHP Q CIWMBQ Complaint Q Educational Visit Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> -Tf n <br /> Physical Ad ress 3 - 1 V \ y ( or��4 <br /> 01 <br /> cAr Inspection Date <br /> Time In Time Out <br /> Business Rep Title11 Q AM Q AM <br /> L l ® PM v (l\ J ® Pi.1 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Passenger Generator <br /> ® � 9 ® ® Outdoor <br /> d Q Al <br /> O Q Closed GPS Latitude @Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ® 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> --------- Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> — <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q # 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date 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 /> 10 Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> -----------_ --- --------- <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 /> ----------------------------------------------------------------- <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> Q Q Other: § <br /> Comments ` u•(/ } �-(� T �l 5- 11 <br /> �i v L.,('l V1.L �V`� L rl C�k,� (,(�v�� �-L t GL r✓ �-(:� w L2 bT-t. <br /> ML <br /> l( _ <br /> k 5 � `4"`� `'� �.o U�Itit.1L. ��'rows -a�f � f�>.��u V� v v,, <br /> Inspection Form Included: Q <br /> Comments Included: Q /- cv � - c� <br /> usi ss Reps Signature Phone Number I spector's Sign lure Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ,J�, E h /f,i 1-- l � 62081 <br /> ".e Croy CIWM13 Yellow Copy:Operator Pink Copy.LEA <br />