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® Waste Tire SUdy & Inspection Repor Inspection Report Number <br /> State of California " - <br /> Gr is CIWMB 181(New ) Survey Form - Page 1 c _l..-, 3. _--, 1 D 6 � 4 1 <br /> California Integrated Waste Management Board J L, <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> "ED�- j - Inspection Type (Fill one) <br /> Site Suffix: Q Routine Q Re inspection Q Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name --- <br /> Inspected By Inspector - <br /> Physical Address - LLL <br /> L• <br /> J Lr <br /> g ;Street <br /> Inspection Date <br /> 'City State ZIP Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> [T <br /> PM <br /> ' ® PM <br /> n r 3,^� � <br /> Operational Status a Business RolePo � � , <br /> (Fill one only) ra SII rpi, (Fill all that apply) ) t1ll{I ' I <br /> /r� <br /> Q Active wt Q Generator � rn� f <br /> N <br /> Gper+ Latitude 0 Closed r � <br /> l <br /> 0 Hauler <br /> - O Inactive Irvrlgh" ✓w�l" nkn P'�� Irl tr,.r`r,.:Y•."; <br /> y hJ� a�nr Y�lb <br /> Longitude - 4t, O End-Use Can t <br /> Q Planned <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder O 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 /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q Q 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 Q 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 Q Referred I CIWMB Enforcement <br /> Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q (2) 1 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> i Q In Compliance - No Violations � <br /> 0 0 Other: § <br /> Comments <br /> �F ,� r n a u��n � %�rnn �lr��;^&; � la a v✓ x��'�,t�i'�c)�:;n� w rL.�t�k,M 7 , <br /> .r +r;. <br /> ,t' r,, x ij �,'� , ",��In� .a �°.r �+� 5 f�� � ,�, .'� �r✓rrvr. � "� �f.r• r ^. <br /> g <br /> e ,riin n�H4 tt,�ra i✓ > ,;. sine y,„ ,;,euW ,�Ma. ..,,•y., 11 'k'" ,nn„rr 1, ..� M„ ddn,`a�'�' � :; p'b a'miv uuv< Sy„ '.n �'7 <br /> ggw <br /> INSTRUCTIONS ON BACK `Correct: X <br /> Incorrect: i � k'ti �` � � _•_ 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />