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Waste <br /> aste Tire Suay & Inspection Report Inspection Report tf N <br /> umber <br /> CIW <br /> State of California 0 6 1MB 181 e <br /> California IntgratdWaseManagement Board Survey Form - Page 1 jn - aL <br /> � <br /> Part A Survey BLUE OR BLACK INK PEN <br /> os� rr c ;, �'ra. w P ✓':'r ,+P,� �✓c o ��y�.ra � y+ �� 'a ut <br /> Specti n � tr gnu a rK xa " � aie pti ar aP Pb aP ;,iafw, <br /> u 9�.L. tip <br /> TPID- ` _ Inspection Type (Fill one) <br /> 1' F <br /> Site Suffix: J `. ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> IF"Local n If Referral,choose referral type(Fill one) <br /> Identifier: t` {.'1 1}L;!� ;{,(r t t` ;i ' i.' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name f t t-' Inspected By Inspector <br /> T . <br /> Physical Address <br /> Street <br /> r } r, Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title � f 1 Q AM [T] <br /> 0 AM <br /> k -7L�L� 0 . <br /> PM 0 PM <br /> I Operational Status +' Business Role <br /> to r� r a ^✓pry raf tr~r z tr � P n <br /> (Fill one only) �I� a � py (Fill all that apply) �1(���� ( <br /> 0 Active ® Generator <br /> ra i �a M o- >� ✓y P, x7 P n�j" 91 <br /> O0Closed <br /> GPS Latitude i�✓✓�P 3i^'7aI't9P�t!aa.w?�r9�P�'MI y^rG� k4y { 4�3a��w��ra <br /> 0 Hauler <br /> a•� ,t 4 P 4 4 r1u n� Mr"��""w`K1fP <br /> Inactive ° T Til' . D� !✓r�✓ Pp1pr t FaOY.'y✓ <br /> Longitude _ w P End- <br /> 0 <br /> n <br /> g Planned 4 i 0 Ed <br /> ' W "kra5�}'kPk ,"�d+ IaP�lr' ku1✓'��1��''! �✓'". <br /> ,.. „ '; .>;'+ ;r^ ^"., ;,, 1✓ja ,u � a 3'i z,y� � ti'w"7'[ a7 a:.P 1 r iPz '"'aG�.�„,�'9�y.�k>rr . <br /> ,,: ,. ...,,. ,.a,; .i w.,>.. r � +P✓ ..NA ,k ..n r >'.nM a+a,'b v �u +.Pfd r r P J*z,�ra asr 5.F�' gP`�r �Y r � A r 1 v v ra a�� i p� <br /> .,,� '$t 8�"S✓ y�� } f W aka r »S a r> w �?r r„A"rP 7i w rw�}m�h tt°�n' �>n .+ r M ,�w y� rr� d rr , vPr <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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 Datum <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 /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred i CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> I <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />' l9CqM.,pharce - No Violations <br /> 0 0 Other: <br /> Comments <br /> _ �tt;i_�`(.1�� �' rf ;.� ,�( ` ! l'„l '�Ct,�j t �;�( t��l17i (1(>' Jt�.� ►'j .:r G'r`�tiQ_ �E�” <br /> �`( f(? y,C✓ J i C. C� G n J t.� Ve c�:c�u� ` �f �Fr�� ✓t-"i 1-1 <br /> r r> <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Reps Signature Phone Number Inspector'sySignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X A�, A ,� P� � p�, 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />