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Waste Tire Su&Y@ Inspection Reporol Ino.tion Report Numt er <br /> ®Sd*' State of Cali81(fornia Ott inf JJ''�j ��''9{� //� <br /> w 04104) <br /> California Integrated fWaste eManagement Board Survey Form - Page 1 1 3 - f V V 6 7 V L <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br />} Site Suffix: <br /> Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local j i 1 If Referral,choose referral type(Fill one) <br /> Identifier: ,y'l. ( -�� ou i ,-{ J 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name -� Inspected By Inspector <br /> ii✓ r l7 C_ _ _� _ <br /> Physical Address <br /> Street <br /> �t } Inspection Date <br /> City State~ ZfP Code Time In Time Out <br /> Business Rep Title r O AM O AM <br /> PM ® PM <br /> C_'o'e f j'•.. (!:l v'L_ JIj r(t✓t, I <br /> Business Role Operational Status it <br /> t, a,^W��"ti l�a�� <br /> � (Fill one only) tiC� ) (Fill all that apply) <br /> / <br /> 0 Active t3 � E v 0 Generator <br /> Oa u, rk <br /> 0 Closed <br /> GPS Latitude <br /> Inactive Hauler��L <br /> Longitude - ® Planned a=. 0 End-Use <br /> ' <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 0 Car Dealer 0 Collection Q._s lgmb Rubber } <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS - - <br /> -- 0 Notice Of Violation 0 Extension <br /> 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 <br /> 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 /> 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 /> �i'-1_'j t:q Ir t: ' .ay IS i.�1 (?CC J r` i - '� J,i✓ V12 0)Qi'I �A ;-L; ol,-1 <br /> 1 <br /> f J <br /> Inspection Form Included: 0, <br /> Comments Included: 0 - <br /> Business,Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X "!� 1_ �� 1 L 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />