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:EELw <br /> Waste Tire S' rey & Inspection. RepoInspection Report Number <br /> ' ■ <br /> CIWMB81California <br /> (New04104) Survey Form - Page 1 1 1 - .1 0 0 6 $ <br /> California Integrated Waste Management Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br />} TPIDj-� r r� y) G - ( Inspection Type (Fill one) <br /> Site Suffix: I ' I J l 7 / @ Routine Q.Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> F11 td, 1 ,�ti <br /> I <br /> 1 - <br /> Street <br /> _ Inspection Date <br /> J <br /> l <br /> I n 0 t - A J ITime In Time Out <br /> City State ZIP Code <br /> Business Rep Title 0.AM O AM <br /> 1MOPM O PM <br /> r <br /> Operational Status Tire Type Businessiness Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> D1IZD� <br /> Active Passenger Q.Generator Outdoor <br /> 0 Q Closed 0 Altered <br /> GPS Latitude m . D Hauler 0 Indoor <br /> 0 0 Inactive Truck <br /> Longitude - 0 Planned OTR Q End Use Container <br /> Business Type (Fill all that apply) <br /> i Q New Tire Dealer O Auto Repair O Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel I <br /> I <br /> O Used Tire Dealer O Auto Body D Car Dealer Q Collection Q Crumb Rubber t <br /> O Service Station Q Hauler Q'A'griculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> _V7, A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation Q Extension <br /> 0 .0 I PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> o- O i PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> .0 0I.PRC§42956-Registration/Decal in Vehicle <br /> Q O !14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 , 0 114 CCR§18459.1 (a)(b)(c)-Tire Program ID'Number from CIWMB . <br /> i14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 1.14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O i 14 CCR§18460.2 Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> J. Q .O 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 Q Other: <br /> Comments <br /> .f .4,11 :,� , .r .:< ':'"+• /1/' 1�o Y Cy , !' s� ii //(till Illi(.S' "✓[9 ' ''f f y <br /> c- l <br />} I _ _ __i/1 D if, �....�c-nom+ _ �`-r `_`'f�_�`<;'- r t, .3'�"•�.s..�- � ---------- -- <br /> t — <br /> 1nspection Form Included: 01'q <br /> I <br /> ' Comments Included 0 <br /> Business Rep's Signature Phone Number Inspector's Silpature Phone Number <br /> INSTRUCTIONS ON BACK [Correct. Incorrect: t 62081 <br /> 9 � E,a l Ik L 1 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ®,` ■ <br />