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r <br /> ■ <br /> «�_ <br /> Waste Tire Sy & Inspection Repo Inspection Report Number <br /> EAi➢r^ua State of CaliforniaClWMB 181 —"`- <br /> w 04104) <br /> Calif Integrated WasteeManagement Board Survey. Form - Page -1 1 4 - 10105621 <br /> . <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br />� TPID- � � - /�J Inspection Type (Fill one) <br /> �Site Suffix: L ; '✓ t @ Routine Q Re-inspection Q Referral Q Observation <br /> Local - _ (( If Referral,choose referral type(Fill one) <br /> Identifier: �� G'( J (���{�� .,!1 Y� .,`J 4 ✓t_ ` 1, Q CHP O CIWMB0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> t ' Inspected By Inspector <br /> Physical Address _ <br /> Street <br /> -t-c-) t / � (� ! 117 Inspection Date 0 V r I <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> / rr ! m � m� PM m e m � PM <br /> f ✓��dn 1 "� 1'''✓ c>`.k- I Q'�1 C l`i' ✓i nrr'. I - — -- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire CountWhole/PTE r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ( ) a fJ � Q Active 0 Passenger ® Generator 0 Outdoor <br /> O Q Closed - 0 Altered <br /> GPS Latitude m . Q.Hauler O: Indoor <br /> Q Q Inactive Truck <br /> Longitude - 0 Planned OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) + <br /> O New Tire Dealer O Auto Repair 0 Trucking Fleet Q Government Q Retreader O Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder ® Other r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> .... ...._-_........-.. <br /> V A :HAULING AND MANIFEST REQUIREMENTS <br /> - Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 11:1 / m / m <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days Jf'�(Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers �r K Q Referred I CIWMB Enforcement <br /> O O 14 CCR§1846.1 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire-De alers or Waste Tire GeneratorsIn Compliance - No Violations <br /> O . Other: § <br /> Comments <br /> P,141 t' <br /> i1 t^ )}�1�y,�� �t tUY1 t�I,{ s` 0(2 �� t� l� (' t (t L' �( t '/eC f-/�r�l�'1 �i<c)e1 <br /> —e, T GtirIr. <br /> v/ <br /> �(It-, j6".( . �c�(� , �.I/� y�✓J ;01f I, I c -t ;I' Q <br /> or q15 or - Gttlr�- �' _71-1 woe <br /> Gt(� Gr1 <br /> Inspection Form Included: 01 <br /> Comments Included: moi+ .r'. _ 1. . lr:..- -::�.�.1. �J-�- - - -!�- .�. . = � /S(. <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> r. <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: ( } E'XJ.A 't 1 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink.Copy:LEA <br /> - <br />