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Waste Tire SU & �n$ Inspection Report Number <br /> ■ __ �y Inspection Report_ ■ <br /> State of California <br /> (New 04104) Survey Form - Page 1 5 1 0 1 0 5 1 4 <br /> Californiar CIWMB 181 <br /> 1(Integrated WasttManagement <br /> Waste Management Board _.._ <br /> Part A Survey BLUE OR BLACK INK PEN <br /> gT­ <br />} TPID- J �7 1 Inspection Type (Fill one) <br /> Site Suffix: ! �/ tJ 5 1 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local g� / If Referral,choose referral type(Fill one) <br /> Identifier: 6 f( �/� ( �. I _�/(f� Y',{/�'' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ( Inspected By Inspector <br /> 1 1 _ <br /> Physical Addr9ss <br /> Street <br /> Inspection Datetd <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> RIC, .f' QPM Q PM <br /> 1 l I C�l l- I L i�ICF �' L�Yt 1 a <br /> Operational Status Business Rolei i <br /> (Fill one only) „ t (Fill all that apply) 1 „�( �Sl� <br /> Active t O Q Generator 1 t^ ft1 r <br /> 0 0 Closed <br /> GPS i( <br /> Latitude . , t <br /> ayx� li3t� };r a��. 0 Hauler <br /> " n i ”; �tir'ay 1 c,t i k i6xn¢yvf <br /> -. 0 InactiveMM <br /> rtlS nr "" to r to ✓ <br /> Longitude - 1 �� <br /> 0 Planned 1'�''rte''; 0 End-Use <br /> � �t"�� ���r�tv''�+4)4 <br /> M*t <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> I 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: §L _ <br /> I Comments1 r <br /> �1 � ( r /0 <br /> is 7 F; —DI L eakoi (-�� �_��:;�� - , <br /> hT 1"_0 .i"G i rC f C I r`1'1 ✓1(�C J C"! - I �.��)r YL[ftp ! C i f(� . <br /> Inspection Form Included: pomp"", PRO"" <br /> 17, <br /> Comments Included: - <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X r AAwa 62081 <br /> -------------- <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />