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Waste Tire Surma _Pnspection Report Insp on Report Number <br /> ®i$GFi State of California <br /> CIWMB Waste <br /> eManag) Survey Form - Page 1 1 0 0 6 $ 5 <br /> California Integrated Waste Management Board ----- - - - - <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> /u <br /> 4 <br /> TPID- (-1 Inspection Type (Fill one) <br /> O / <br /> Site Suffix: �/ `-[ Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ( r"1 6 E' 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> v 1 <br /> Fi <br /> Street 0 <br /> '�1 Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title (D AM AM <br /> PMLU <br /> It— O PM <br /> ' � r 1 `� � i Vtl e I I ���v11E?✓- t7�,(Q�.F Ela � "� �r����) r �"�.�.,_' <br /> F,Operational Status�tT (� Business Role Storage Type <br /> (Fill one only) I II (Fill all that apply) fill all that apply) <br /> f, <br /> Active (0 Generator Q Outdoor <br /> � Q Closed "° `` <br /> Latitude <br /> GPS Q Hauler Q In door <br /> D Q Inactive <br /> Longitude – Q Planned Pa y� aW Q End-Use <br /> ;r" <br /> &C! �.��f'%Mrq�!���"r��aa",�+ 3b��� �.�l+a., �,(�C�+� �t•: F"1 <br /> ,,4��+1�� '� �t�( d "r,�)''p.�w ,..�.::,�'�..•��.�..,;a, a y z., ")'�.�1��.�tw.q wb +> � M r M ,r ����r�k�r�, r l p <br /> -1 a..u•,..a�...��� .6.. �J. ..�x...�...�,�.�" 2 w '.5�_. t.w .�"r.�.r nl,..�1...�,.,„�.�.a .� .�,'".,..,.,.�.�..�1.�liv�,�. <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler 0 Tire Derived 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 T - i_, (�(1.,1.1JPf _✓A1C <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A WAU§ING AND MANIFEST REQUIREMENTS P Q Notice Of Violation Q Extension <br /> Q O <br /> PRC 42951 -Waste Tire Hauler Registration and Trans ort of Tires <br /> Q 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 m m / m <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 <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 1' <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Deferred/CIWMB Enforcement <br /> Q O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q In Compliance -No Violations <br /> Q Q Other: § <br /> Comments - � ' ( - ! _ <br /> t1` ILYA Ilk `IC, q dm It� l'��(fr✓QtfC��� d� j'! Imo()✓ Yi.' !_-Gj ' �' k- <br /> 7t�t� Ir1C' ' YI0j{ �t : _fl, �e0 .j r,ry;t .Fr ��<i k �rc�_.ilF✓ CSE c� y�tC"ct l �,: �, <br /> f11 w� ?IAI, ( ((u�� �I� C''taJn�e V510�5 T CI p� t�— <br /> N'1 ,1 )��r, �'C' '�/" I 44 <br /> Inspection Form Included: Q <br /> Comments Included: QI - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: 62081 <br /> ')( + �'��� I_,I; r 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />