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Mste Tire S y & Inspection Repol Inspection Report Number <br /> ■ aFF0 State of California ti <br /> Fr , ` Survey Form - Page 1 T I 1 9 - 1 01 31 4: 0 <br /> CIWMB 181 New 04104 <br /> California Integrated Waste Management Board \f` <br /> Part A- Survey BLUE OR BLACK'INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection i ;Inspection Type (Fill one) e <br /> Site Suffix: O EEI' (0 Routine Q Re-inspection Q Referral 0 Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: 4 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> i <br /> ti. y _ /.�-� I r✓/>'%moi r�l <br /> Physical Address10 / //,/ fG <br /> d <br /> '�! c• V i' ll/r t lf?I'r tl/t <br /> Street <br /> i Inspection Date <br /> City r State ZIP Code Time In Time Out <br /> Business Rep Title 0 AMQ AM <br /> EEIMOPM m m 0 P <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 /> / <br /> ❑ � � (5 Active (5 Passenger (a Generator Outdoor <br /> D Q Closed Altered <br /> GPS Latitude m • Q Hauler Indoor <br /> O Q Inactive @ Truck <br /> Lonit!ude ~ — O Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q AuIcRepair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived FuelI <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubb2lir / I <br /> Q Service Station Q Hauler O Agriculture Q Shredder (a Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and-End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br /> O I O I PRC§42951 -Waste Tire Hauler.Registration and Transport of Tires <br /> O O I PR §42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O .O PRC <br /> 42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB 7, 1/ <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 114 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 014 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement' <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations Y <br /> O 0 Other: § <br /> Comments l / �f /`� ' /] 2%�Y. , J( �r.� ;.l�r' /l.c�rr � 'Z, -f <br /> A& <br /> r' / <br /> �!I t /I >� 3•.'i I-e-el' 'P r , Y.f��♦'f <br /> i�Lf C✓/-. ,'7 r //r •// 6 j/_.,�rr �r /•�/., j�� ✓�/'r"'!r frt'.vr ./� r %!' Ir r:/._;✓ � lG/.9:7/� <br /> 1 /%7 •`✓ � � 'y�-f^��f � b � r L� ';-/-'�� ��/ � 4. � i^V�U..`�� // l(.f-Cay' / <br /> Inspection Form Included: C)' <br /> Comments Included: (�" ._ .-- - �- .'------ <br /> _nature <br /> .. <br /> �,euslness Rep's Signature Phone Number/ Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X) 3 AI p L� E 1, 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> r <br />