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-� Waste Tire Su�y & Inspection Reportonspection Report Number <br /> State of 181(New <br /> eniaCIWMB <br /> California Integrated WasteManagementBoard Survey Form - Page 1 <br /> ----- <br /> Part A- Survev BLUE OR BLACK INK PEN <br /> u"Iw <br /> r�� Fw1.d1,3^A'�Yltw"`'ga r°"�+ ',,�✓., ?���''"""..�! ,�ai,�r",»�?,^'�.w .`"u�„w",".uP'..', va".."✓_`rd;�. <br /> TPID- - Inspection Type (Fill one) <br /> I Site Suffix: _ 0 Routine Q Re-inspection 0 Referral 0 Observation <br /> Local - 1,��� If Referral,choose referral type(Fill one) <br /> Identifier ---^ ' <br /> _.,_. ...,_.......--- <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> r ..----�- Inspected By Inspector <br /> t I <br /> Physical Address � � � � 1 - <br /> Street } <br /> Inspection Date <br /> c' ' . <br /> `V�..4-. _ 'L '•,�.... ems_.-.A 1. r'� (.'d,`-> <br /> City State ZIP Code Time In Time Out <br /> Business Rep TitleAM <br /> Q Q AM <br /> r LH QPM QPM <br /> yy // <br /> Operational Status l+ply m y � Business Role r <br /> s'urt� 4 `yi „wNrx <br /> (Fill one only) 1i � { r (Fill all that apply) 1 � <br /> c <br /> " Q Active k Q Generator „fns' <br /> DClosed � w � <br /> CIPS Latitude 0 f rku� 0 Hauler <br /> 0 Inactive <br /> Longitude — 0 Planned 1�tt w 0 End-Use <br /> . d..,:. <br /> ✓��.k,{";,;Jim=-:. <br /> E—E—E—F-7 <br /> ,,n...�. �1.w:�:;•:.'^ ,.A ..,_.�;4e �Y <br /> .„. w� <br /> � � �� ��.� <br /> 0 New Tire Dealer 0 Auto�Repair <br /> 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 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - --- I <br /> V A - HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice Of Violation 0 Extension <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 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred t 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 <br /> 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> 7_ <br /> .,.. <br /> Inspection Form Irtcl� l <br /> ,""" rx�"rS '7,+ ww"r + `9mF rrwr' <br /> Comments Included: (� :'`_ <br /> Business Rep's Signature Phone.Number Inspectors Signature Rhone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK 'i Correct:ilk Incorrect: I l l_ 1 w <br /> "W <br /> White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA <br />