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Waite Tire Sy & Inspection Repor nspection Report Number ■ <br /> n3" State of California - <br /> arnia <br /> CIWMB Waste <br /> eManage) Survey Form - Page 1 5 - 1 0 1 3 0 7 9 <br /> California Integrated Waste Management Board <br /> Part <br /> yy A- Surve BLUE OR BLACK INK PEN <br /> y...'��.� `nuyry+„rg;S� z�� �„�Sa°+r <br /> -.. E <br /> TPID- '71 1 1 ,` [� � Inspection Type (Fill one) <br /> Site Suffix: V �, ' # Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local !� ( 7r'`1 _ If Referral,choose referral type(Fill one) <br /> Identifier: t 1Ly' C ( 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected B Inspector <br /> Y <br /> .._ In ctor <br /> p �~ r <br /> Physical Address <br /> J�tf! �( <br /> Street V 1 r 1 <br /> Inspection Date <br /> City Sate ZIP Code Time In Time Out <br />/± Business Rep Title rr O AM O AM <br /> 0 P � 0 P <br /> Operational Status;r"�et €k,p,lBusiness Roled', <br /> r (Fill one only) li 'Oa( ) )� (Fill all that apply) �� <br /> 0 Active i eG� ? 0 Generator <br /> ��++ ��++ Latitude D ® Closed ,+ � " 0, artt��r;a` <br /> VPJ �.� �' �' i ,lu a7�) w. 0 Hauler +'rw✓ +� C� p! r+`rr <br /> inactive <br /> W r l ,+,� r u r +" r + M ✓ <br /> Longitude LonF F <br /> O <br /> 0 rtEnd-Usey 1# r rpt <br /> g Planned ti, r c „M' " � � <br /> ,a:ur rr:: ! i,.tir � 1 y d�-,^-�,,�,• ��u �' ��r 5-',:a' � N¢ -�;^µ y.���,.ut„ F���7r�" <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 Date M / m / m <br /> 0 0 14 CCR§18459 .1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 1 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/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 GeneratorsIi In Compliance - No Violations <br /> 0 1 0 'Other: § <br /> Comments � ( <br /> J , <br /> Imo( t, t < -( L ' _r YrC'.� Ivc( �� L � 1�'Y'-✓rft <br /> b <br /> I � <br /> 1797eps <br /> Comments Included. 0Business ignature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X p A .i;r 2 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />