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Waste Tire Su^ & Inspection Report 4#nspection Report Number <br /> State of California <br /> �r CIWMB 181(New <br /> Manage) Survey Form - Page 1 I _ 6 - 1 0 � 3 0 ,� 0 <br /> California Integrated Waste Management Board ♦ "J' ��_. _.... <br /> Part A Survey BLUE OR BLACK INK PEN <br /> r W Cr M.F <br /> n 'r r 1 t <br /> ^i.' ✓d z.,.w w d l,�w;.:,f:ry u,^, k^ Iw.'., r"h .yr Y.. i'InS @Ctlgfl .. <br /> R-011- <br /> P r rar._ F w , k Vlw �;✓st r k a>✓•4! rr r r r i w s <br /> f �.rar� ^ � a �ud <br /> TPID- �-: Y '"'� .� �-^ /'—� ^+ Inspection Type (Fill one) <br /> Site Suffix: I '� 1 ( l_;` 1 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: x� > ?� <br /> U Gl t y 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> , <br /> Physical.Address Ll <br /> Street — <br /> '1 , Inspection Date ) <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title — O AM 0 AM <br /> t jJ f1 �f f �- i /- -; �_. O PM O PM <br /> -- i Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) {Fill all that app1� (Fill all that apply) (Fill all that apply) <br /> , <br /> ® Active 0 Passenger° Generator Outdoor <br /> t <br /> r7j7T <br /> 1 o O Closed (� Altered b,1 <br /> Latitude <br /> GPS 0 Hauler 0 Indoor <br /> D 0 Inactive 0 Truck <br /> Longitude – 0 Planned 0 OTR End-Use Gontame <br /> R <br /> Business Type (Fill all that apply} "1[ <br /> 0 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 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 /> ' <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/CIWMB Enforcement I <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § _ <br /> Comments } `� <br /> V►C( S fit ` <br /> IAN 0ti /+. CiLI <,�) /2j" <br /> 47 <br /> Inspection Form Included: 0- <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: h <br /> �_. __.. <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />