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on Report Number
<br /> Waste Tire Sum* & Inspection Report 'specti ■
<br /> State of California
<br /> ° I Survey Form - Pagel i i - 1 025852
<br /> CIWMB 181 New 04104
<br /> California Integrated Waste Management Board
<br /> Part A Survey BLUE OR BLACK INK PEN
<br /> NOa 1 t m yrc ^1"F,'' ✓ 79"'s" k r, b'-� - ^�a ..w. r„ u� pgg
<br />+ TPID- Q Inspection Type (Fill one)
<br /> Site Suffix: 3 -:71 Q Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier:
<br /> .-% .. �'. 71 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name
<br /> Inspected B y Inspector
<br /> ector
<br /> Physical Address� �
<br /> Street r
<br /> Inspection Date I7-1
<br /> !'ifiv State ZIP Code
<br /> Time In Time Out
<br /> Business Rep Title OAM m 0 AM
<br /> - FTI 0 PM � � L� 0PM
<br /> Operational Status t Business Role
<br /> (Fill one only) µ' Ifllti) (Fill all that apply) 1��MYIIti1t ; +pl
<br /> Tire" ount llhole/PTE\ itrrww
<br /> D 1 g .. a :✓ ✓ a a 9 rr4s✓ rA h.
<br /> < „ ®Active a � � Q Generator ire
<br /> 0¢,u, Closed H dR,*'�a✓���! , �y,Y ,ln,✓I ✓r 1,k+,�+n y��
<br /> GPS�+ Latitude � y�ir�, u ! 1 {!�,✓ 5� 3 ,✓/ a
<br /> �... _ �G r✓af✓+� 1�✓✓ ✓y� 0 Hauler ����t�� t+✓
<br /> 0 Inactive T� /` �¢ld ✓a tr f� ✓ ,
<br /> r✓ fid';' �rA ,t 7a,r ..� s ! i5 !f
<br /> Longitude - ✓ ✓y ,a 0zd
<br /> 0 Planned End-Use
<br /> ria � � ✓",ka"p�r,l,,dM,1 „,+::✓ k"^✓�,�`a
<br /> Busxne� '
<br /> 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 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 j 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 j
<br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/ IWMB 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 In Compliance - No Violations
<br /> 0 1 0 Other: §
<br /> Comments
<br /> r * °'i✓n'vw, ✓e r� s�k s t���m " !;"cr"6 Fs,N�- �, r<'"" wn�^i r.� ^t ,s.: �` �" ",.n °r"a "��r w ��,;.gip ,:";✓ l�d." r�r+i` �°+ Y✓;w,
<br /> v"! ✓,.,.,,.. .,�, �',TM� M�'✓i ✓�'" .,: ✓ e✓,. �; ,.^t�� ,a� ,,a,r �;.,,;;,"w,�"��fl"'<, €'`:,: �„ - 1 l°°, „� "� ;�"� a'�a�� ! 7�,.
<br /> „� t* ✓' ":x y <a �,.„ ). r, :aat � M1t r.,✓ a,�,�, ��; �"��''�,y�n",�",'+.`,; �' � .✓�.�' � -.a � °r ,,.
<br /> r
<br /> �; ,, a " � .. r ✓, f'"� �h1,�:`w ✓ �ry°'ate ai� 4t�� tt ! � e i � !°"r `4"..,'�i" ^�,�;",✓ ay+. � " , d a ✓t"
<br /> INSTRUCTIONS ON BACK Correct:I* incorrect: i i"! r mM P62081
<br /> ■ -- -
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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