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Inspection Report Number <br /> Waste Tire Suey & inspection Repor ■ <br /> State of California <br /> California Integrated IWMB 1Was eeManagern t Board Survey Form - Page 1 L� V f V 1065 <br /> Part A Survey ,,,,-"--BLUE OR BLACK INK PEN <br /> ir )f r 'r 4 "d { s r Ins et?pn Dot+ y*,na§ Y«".:fr•f n n w^away;, +n",r"y"a 1 t,r y y ^ r <br /> 1 <br /> 7Pstness,Prol® mrP4,tib �:rvn d. Yr. ^«, � ... .t.L f....� _. �,., w. <br /> Site - f } f Inspection Type (Fill one) <br /> Site Suffix: F3 F9-, P77, <br /> / I - i�__,-f_.__� Q -inspectionQ Q <br /> 3 r 9) Routine Re Referral Observation <br /> Local _ ''t If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> / Inspected By Inspector <br /> '1 ,� C lf� o l I r <br /> Physical Address <br /> Street <br /> I Inspection Date <br /> CrtyState ZIP Code Time In Time Out <br /> Business Rep Title0 AM �I AM <br /> 0 PM W m 0 PM <br /> Operational Status¢Ir' Ir „y° fi Business Role & tr <br /> (Fill one only) ( Il ) tk ^ Pkt (Fill all that apply) <br /> w ✓ a � r � A ^ ✓� � ^ <br /> p ✓t G,�,yM"P,r�rt e�° �"r��a�"�"r�tq��'4✓�✓� N. <br /> , "✓ a r?a� r Generator '���" '" W�H^"11�`rjr <br /> Active "��"�f ��� n ���ri <br /> " <br /> r a ��✓yr� �✓� ��r�✓�� 4 bf�r � �y f b�a <br /> Closed p + ib ✓. i�ggar"''"�y dyt^o"tm �>aa <br /> r <br /> GPS Latitude Q + I�� 1 ) Q <br /> ; r w Hauler � ti <br /> — Q Inactive <br /> O �✓ fr�r � ��au l/. ✓y'�'�ah M�^�^rl� '"fir a'"rw^ <br /> Longitude - Q Planned ttQ End Use r �� " i� t`✓a?" <br /> ,. .>, a ,:a " y3 il^�✓:.�a �"^}�4 l7,k ar�4"^,:r &�`t i n��vtn a�' ✓fy�^,' ("��4'Nar �rr �rr'"^��r n",�x �sg���' rt <br /> Wxy tirf, <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 /> Q Service Station Q Hauler Q Agriculture Q Shredder ( Other i / .n ;�� r f( { �( ' <br /> - -- - - �j 1. * �r , 1 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENI Mluf N. <br /> _ - --- - - <br /> U A ,j HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport 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 j <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred t CIWMB Enforcement <br /> Q Q 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 "5 t. 'r'k" <br /> o,Violations <br /> Q Q Other: § <br /> {j 1 +l J/ L <br /> Comments . ��(U�'? 01 P,: i J <br /> ! f <br /> INSTRUCTIONS ON BACK Correct: incorrect X i"� �� E'X A M P I 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> ■ <br />