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=� Waste Tire Suy & Inspection Report nspection Report Number <br /> sHI ■ <br /> 1399 State B California <br /> Cgrated 1 teManag4) Survey Form - Page 1 <br /> Cal+forma Integrated Waste Management Board � 3' I! <br /> Part A-_Survey BLUE OR BLACK INK PEN <br /> �AS9n4S8r l�� '+Yl "d +l � Hit °r" ti,*s l $ " k <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ) - <br /> f C Z I Q Routine Q Re-inspection Q Referral (J) Observation <br /> Identifier:Local -� Y .-- If Referral,choose referral type(Fill one) <br /> --� � , <br /> .�}•c r. �. .�� ,; G/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Ins ected B <br /> p Y Inspector <br /> Physical Address <br /> r r ` <br /> Street �- <br /> •-� Inspection Date <br /> City— State zip Code <br /> - --- J Time In Time Out 0 AM <br /> Business Rep Title 0 AM <br /> 0 PM �—_J ' �� 0 PM <br /> -, : Operational Status °i 4 Business Role ` <br /> (Fill one only) 1� err �� Fill all that apply) <br /> t� �^1a a <br /> Active � r� ���� IS Generator <br /> F7 <br /> -ETI � <br /> OLatitude Q Closed Q Hauler <br /> O Inactive <br /> n <br /> Longitude Cil �t ��kN � End- <br /> 0 �Mdr hwGd' t i °! <br /> 9 Plannedtkz«��" Q Use ti�Cd $ ){ 1 i+i <br /> I V M+ v��,i�f p�� if��,r t e�,� ,t„hy, yf �d�r�,�r✓�r twr r t,? <br /> + <br /> ..r_W,,,,+'.� <br /> Q New Tire Dealer Q Auto Repair Q 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 /> QService Station Q Hauler Q Agriculture Q Shredder Other <br /> J <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V i A HAUL�NG AND MANIFEST REQUIREMENTS <br /> PRC 42951 -Waste Tire Hauler Re Istration and Trans ort of Tires <br /> Q a Notice Of Violation Q Extension <br /> Qr § 9 p <br /> 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 <br /> Q Q 14 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 orFJXT) `2] <br /> @ <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 Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators an { <br /> § Q In Compliance - No Violations <br /> Q Q Other: <br /> Comments <br /> _g <br /> rt� _ <br /> li <br /> F • INSTRUCTIONS ON BACK ! Correct:* Incorrect V;� X A M �� 62081 <br /> White Copy:CIWNB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 4 � tti <br />