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■ Waste Tire Sur@y & Inspection Report nspection Report number <br /> iWu "n State of California ,.q — j ■ <br /> ClWMB grated Waste <br /> Survey Form - Page 1 = E i t: J t <br /> California Integrated Waste Management Board <br /> Part A- Suryey_ � BLUE OR BLACK INK PEN <br /> Elustness Profile; - _ _ l Inspection DeEatls `x <br /> I TPID- r r l Inspection Type (Fill one) <br /> Site Suffix:_ ! ® Routine 0 Re-inspection 0 Referral O Observation <br /> Local - I - --- - - If Referral,choose referral type(Fill one) <br /> Identifier: I <br /> I Q CHP 0 CIWMB Q Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected B <br /> p Y Inspector I <br /> Physical Address - +' <br /> r/l {, j L_ <br /> Street / <br /> Inspection Date <br /> / n, _1 <br /> L L� <br /> City' State LIP Cod-: Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> PM 0 PM <br /> Operational Status ,f ire pe' Business Role <br /> r � ' (Fill one only) illail thatpply) (Fill all-that apply) <br /> Tire 'Daft ( oto�! 1`�`j, <br /> # Active aPBS$ef Igerr Generator M a,ti <br /> D Q Closed Q Altered O W <br /> GPS Latitude Hauler <br /> O 0 Inactive <br /> i <br /> Longitude - O Planned End-Use <br /> Business Type (Fill all#hat""ap <br /> Q New Tire Dealer O Auto Repair O Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> O Service Station Q Hauler 0 Agriculture O Shredder O 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 /> Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date T / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _"— <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> C.. �, f t; 1 ✓ �1 i ' r <br /> I t .'Lt :-J( tlr r t.l ( , / 1 cudY A { ✓r ; Uryy I rl n( i J <br /> 3 ,/(t,l� <br /> Inspection Forrri 'Included <br /> Comments Included Q r - <br /> ------ <br /> 1ness Rep's Signature Phone Number os Signature Phone Number j <br /> -- - <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:1110 Incorrect: X � ,r i I_ [ 1 <br /> ■ ------ <br /> �__�_ . ______ O ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />