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Waste .TireSuRe &'Ins ection Re or `Inspection Report Number <br /> &6@ State of California Y h - _� ■ <br /> CJWMB grated Waste <br /> eManag) Survey Form - Page 1 6 - 10. 1- 4 870. <br /> California Integrated Waste Management Board <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- !. Inspection Type (Fill one) <br /> Site Suffix:" 3191 QJ_D] LOJ (0) Routine 0 Re-inspection QReferral <br /> Q Observation <br /> Local _ = �fs � If Referral,choose referral type(Fill one) <br /> Identifier: Sc,V1\ J- IA'lV-\ u V1 I Q CHP O CIWMB Q Complaint :Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> P y Inspector <br /> I � Pt`I �o r11er'I C� �Ir� e+rJi <br /> Physical Address <br /> CILI <br /> S <br /> Vl <br /> Street <br /> Inspection Date <br /> Sck-Iv�-1 Com.: r520� tl <br /> City State Zlp Code Time In Time Out <br /> Business p Title 0 AM 0 AM <br /> 7 <br /> LEI* M 0 PM ' O PM <br /> o 4 o+ l � llt�rtru0 vJ vt ter _ -- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> D O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ! � <br /> Q Active (a)Passenger (E) Generator Outdoor <br /> T1 1 O Q Close � ere <br /> Closed Altered <br /> GPS Latitude m . O Hauler 0 Indoor <br /> 1 O 0 Inactive 0.Truck <br /> Longitude - O Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 'Q Auto.Repair O Trucking Fleet Q Government._,10 Retreader Q Dismantler O Tire Derived Fuel <br /> 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 A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q l PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Notice Of Violation O Extension <br /> O Q +PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O I PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements �? Date <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 /> 0 Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q 1 Q Other: § <br /> Comments klfjr1;1P✓ F <br /> Ila 1C <br /> ac, lf'r �GG� !j2 ✓(' �'� ` � rl �(tC�#;1 (lS U <br /> Moab StFr,►^ S1' i-vVpvcar, o✓a,� 461 � -f�-Q � qlalelv S -Itfe_S p6t11114 ()4r(r <br /> li—r 1 <br /> 01141MIL t.l(PS 51kc-4 oul �,- <br /> make- Sure Wet J +n ,j� � ) <br /> C rf �y1�1''(�r,l .: _CLI� ,�IlPr� r �t� 0Dfn.' Ie't It , <br /> Inspection Form Included: ] <br /> Comments Included - { _..__ = <br /> Business Rep's Signature Phone Number Inspector's Signature Y r Phone Number <br /> INSTRUCTIONS ON BACKCorrect:0 Incorrect: �X) r, E� ,A!M p °,L 3 <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA S <br />