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Waste Tire Su y & Inspection Repornspection Report Number ■ <br /> State of Survey Form - Page 1 I 3 - 'l <br /> CIWMBB181(New 04/04) <br /> California Integrated Waste Management Board ...-- ..... - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> N qj ( p <br />} TPID- ,? _� _ ' - [A;J / <br /> Inspection Type (Fill one) <br /> Site Suffix: 1 <br /> ®' Routine 0 Re-inspection 0 Referral 0 Observation ' <br /> Local1 If Referral,choose referral type(Fill one) <br /> Identifier: r ;t. JLr ! . [ i CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> / r ` FFA <br /> Ll J) <br /> Physical Address - <br /> _ ) LtU- <br /> I <br /> Street <br /> i} Inspection Date <br /> Time In Time Out <br /> City _ State ZIP CoCodeTi -.,..._._ —Business Rep Title O AM 0 AM <br /> ! •-_��, � It(� � PM EE : � 0 PM <br /> �� � � rn <br /> Operational Status��� ��� `yr ,� Business Role <br /> (Fill one only) (Fill(Fill all that apply) <br /> (D Active re) neerwr�' (ftGenerator <br /> r'� Oyu <br /> D 0 Closed '(� Itl ," <br /> GPS Latitude �rr� ra,)k '� „ °; 0 Hauler <br /> 0Inactive °t� i� a <br /> � <br /> Longitude Q Planned r �K 0 End-Use <br /> Bustne <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 @ 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 <br /> 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 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 /> i <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 Generators 0 In Compliance - No Violations <br /> 0 0 Other: §. <br /> Comments ' <br /> rfl1VC/t{t(.' <br /> f t <br /> or / J /,r< - �trftC' <br /> ,i' zw Y i � � r ^" yvih F r ,< c" •,r,�" ✓!r"alr a"'��"�'",a:. P Www r,Nzw,a rry {µ.,; �" �f�w,1� � w,wz m t2!r w r t r m ayw �w✓a r 1:' a n ;f'Y! ✓ ^frp•q /i <br /> •,,,,i ,dr,c,, .,;rF"" r r,:r w p a` �r x r ✓r S fan ai a i"a '.) i �;w f`7 t �r�,� a.,l r�`'w'',� a/� �'� r <br /> ��� �, s _.,��te��a Sl�kte�u(re y _ I�honeNUrn� f, ���'��� I^ Y -_ __�___ �� t+�M�,�� dt► . <br /> INSTRUCTIONS ON BACK Correct: Incorrect. X A M pp 1 a' 3. 62081 <br /> -- --- - - - _- - © S <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />