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Waste Tire Su ..s y & inspection Repor,� - Inspection Reort Number-----------p---- -- <br /> - YialTCi State of California /h a (� <br /> CIWMB1811(New04104) Survey Form - Page 1 3 7 1 0 0 0 4 � � <br /> California Integrated Waste Management Board --------- --- <br /> BLUE OR BLACK INK PEN <br /> Part Ass P o�e-y <br /> - - - <br /> ins ection Details _ <br /> - - <br /> TPID- ' 0 Inspection Type (Fill one) <br /> Site Suffix: l I I Q Routine Q Re inspection Q Referral Q Observation <br /> Local —� If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address I_-1 -0 ` J �� <br /> L3 <br /> L. 10 Da 5 Unca--------------� _r_ <br /> Inspection Date 07 <br /> � - D � 05 <br /> Stare -_1P Code ' Time a In Time Out <br /> Business Rep Title 0 AM O AM <br /> r5J P55� - - - --- - <br /> / -- <br /> �L Operational StatusTire Type Business Role Storage Type <br /> Tire count(Whole/PTE) s f i (Fill one only) (Fill all that apply)', (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger ® Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> Latitude . <br /> Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude m Q PlannedQ OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derided 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 ENFORCEMENTSTATI S <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> I Q Notice Of Violation Q Extension <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> I <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> 00 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O I (Required for NOV or EXT) <br /> 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> QII 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 Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> O O Other: § -- <br /> Comments aC4 'l —��—Q f OCAS 4�J� AlL— <br /> 4-Nq6 rk ��°G� aAU 4f n,; -. - <br /> Inspection Form Included: Q; <br /> Comments Included: O Business Rep's Signature Phone Number Inspector's Signa a:. <br /> ............. _ <br /> Signature Phone Number <br /> P . - <br /> INSTRUCTIONS ON BACK [ Correct 0 Incorrect: X �A rn�, 62081 <br /> ----- - <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />