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Waste Tire Sey & Inspection Re or Inspection Report Number <br /> p -10- <br /> _ - <br /> State of California j <br /> marCIWMB 181(New <br /> Manage) survey Form - Page 1 �1 3 - 0 Z 0 9 1 t0 <br /> Californiania Integrated Waste Management Board y _ <br /> Part A Surve BLUE OR BLACK INK PEN <br /> TPID- 7!, <br /> spection Type (Fill one) <br /> Site Suffix: 1 1 1_•=.1!J <br /> _ Routine 0 Re-inspection 0 Referral 0 Observation <br /> i <br /> Local � Referral,choose referral type(Fill one) <br /> Identifier ` CAn ` TO Ct 1 1C� �.Q lA(1 �} ICHP CIWMB <br /> Q Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> P y Inspector <br /> LA <br /> Phys cal Address ' <br /> f I� 11 II <br /> Street <br /> Inspection Date Q / / F� -� <br /> ���_Q_ r �___..__ C-r ' G t ' { 'e Time In _ Time OutF-1- _ _ <br /> J State ZIP Code <br /> Business Rep Title 11 0 AM AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role { ;; <br /> (Fill one only) (Fill all that apply) (Fill all that apply) �Ial` �� <br /> Active 0 Passenger 0 Generator " <br /> GPS Latitude ETI •==11 <br /> D � Closed Q Altered <br /> 0 Hauler <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 0 OTR 0 End- <br /> 0 New Tire Dealer 0 Auto Repair ® 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 ; AHAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 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 IE <br /> / III / III <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 /> a,:t f + -�j t c::r)�r_ rr ear F , _ &ar _—tlln ,,c } <br /> o�CQ --Cc-C-o r d'CLQ Q k� �/1 -, _ <br /> 1 1 <br /> Inspection Form Included: <br /> p O' <br /> Comments Included; 0 _ <br /> Business Rep's Signature,- Phone Number Inspector's Signature Phone Number <br /> - <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 62081, }�", I_;; <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />