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G Inspection Report Number <br /> Waste Tire e & Inspection Re <br /> 211 <br /> State of California CaliforniaiIntegrated CIWMB fWasle81 eManagementBoard Survey Form - Page 1 ,.1. I �., ! V V 6 4 5 IAF - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- ) Inspection Type (Fill one) <br /> Site Suffix: 1 Z/ � - ! Q Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP O CIWMB Q Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical,AddressL-1 ( <br /> L! I L 110 ` ' <br /> Street <br /> Inspection Date <br /> _ <br /> City State ZIP Code Time In Time Out M <br /> Business Rep Title Q PM Q AM = 0 PM <br /> ` t <br /> Operational Status R �k r ` " Business Role <br /> (F�Ione only) % � ) (Fill all that apply) <br /> ,^W�'40"/L�t ����, a w r/ pdt ;,,fir��r�✓ �'�l'�t�ny . <br /> Q Activera�f � � �t Q Generator " lOIgpa <br /> �.� b fid' Mtn r nr�ntiW r''n"tie ✓ e rd <br /> . 0 <br /> Q Closed <br /> GPS Latitude Q InactiveQ Hauler <br /> 4Xa <br /> o I�t �defa Mt' �t ` <br /> Lo itude 0 Planned i � Q End-Use <br /> n r oW� rll <br /> Q New Tire Dealer \QAuto Repair Q Trucking Fleet Q Government O Retreader O Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station Q ulerQ Agriculture Q Shredder O Other <br /> Part B - Inspection of Was a Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANI ST REQUIREMENTS <br /> O Notice Of Violation 0 Extension <br /> Q Q PRC§42951 -Waste Tire auler Registration and Transport of Tires <br /> O O PRC§42953-Contracts w�ith <br /> �egistered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible�'ntities Complying with Manifesting Requirements Date m m / m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§ 18459.2.1 -Submittal of MM�nifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Mani6t Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 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 O In Compliance - No Violations <br /> Q � Other: § <br /> Comments n, I <br /> i <br /> Inspection Form Included: <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> X62081 <br /> a '. 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: � r �, �4h �' L r 213 <br /> �- White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />