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Waste Tire Su � y & Inspection Report p <br /> nS ection Report Number <br /> _r <br /> State of Cal <br /> � .. j _ <br /> California lnegrat dWalsteManagement Board Survey Form - Page 1 i,. A f 00--l-61--3.5 4_ {' <br /> Part A S BLUE OR BLACK INK PEN <br /> a <br />} TPID- - � Inspection Type (Fill one) <br /> Site Suffix: �% �� �. � r Q Routine Q Re-inspection Q Referral Q Observation <br /> Local r" ._.- If Referral,choose referral type(Fill one) <br /> Identifier: 1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> I- Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address f ' / <br /> L. <br /> Street <br /> Inspection Date �-_°- <br /> - i <br /> - <br /> city — StateF/.P� Time In Time Out <br /> Business Rep Title O AM Q AM <br /> rY ® PM [_:U <br /> s� w` 0 PM <br /> 4 „ Operational Status Business Role <br /> tl1 y r r <br /> ' °� (Fill one only) p � 6 (Fill all that apply) <br /> Active <br /> d '.x ti a (R)Generator <br /> AA` <br /> I �� y'tFw+ i°�.r,�"�'3nr^"taS����lt�. <br /> Q Closed t i + �t <br /> � <br /> Latitude t <br /> TPS Q Hauler <br /> D <br /> Q Inactive <br /> Longitude - Q �" Q End-U Planned ( <br /> Q New Tire Dealer Q Auto Repair (a Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> �iy d <br /> V A j HAULING AND MANIFEST REQUIREMENTS- <br /> Q Notice'Of Violation Q Extensian <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tire <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date mm / m <br /> Q Q 114 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB � ' <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 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 <br /> Q Q Other: § <br /> Comments <br /> 7 1 _ <br /> . '4� 2%... il�.^��".;����.���d�:.._.�:". '�.�,�M��I��,�?�1'� I ( �$ �� ._.�' ", �n�A��i Fr �i,�w'�pa�➢�"rytn,. ��� + ,i <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E ' A M f' J . 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA _ ® ■ <br />