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Inspection Ins Report Number <br /> = Waste Tire Su, ,✓ey & Inspection Repor ,,State p p <br /> x„11 ClWM 181(New 04104) <br /> California Integrated Waste Management Board Survey Form - Page 1 V 10 V 961 <br /> Part A- Survev BLUE OR BLACK INK PEN <br /> �inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ' 3I G 1 Z - 1 i 2 r G I @ Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: n r 7C�Q UI f) C-0 U rQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> f1�.4-i i �0 1-1Gr1.� GGlu�tr�G I f� <br /> Physical Address _ (5 d I Y,,(IS I CA LU G4�. <br /> Street <br /> Inspection Date <br /> A 91:-) z0,(-City State ZIP Cock: Time In Time Out <br /> Business Rep Title O AM O AM <br /> 11 MOPM [1] ' 0P <br /> tic\CA- f j I 1 n I Operational Status Tire Type Business Role Storagejap <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all thQ Active Q Passenger Q Generator Q Outd0 Q Closed Q Altered <br /> GPS Latitude ,I I I I I QHQ <br /> auler Indoor <br /> 0 (9 Inactive _Q Truck <br /> Longitude - Q Planned Q OTR End-Use Q containel <br /> FT7d I I <br /> I IBusiness <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 /> QService Station QHauler 0 Agriculture QShredder Other <br /> Q er V- fo 0- <br /> Part <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 /> 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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB F] <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 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/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 Q in Compliance - No Violations <br /> Q Q Other: § <br /> Comments —,T ` ��� � �O <br /> _�� tt�s_-ter n�Lfi,csh n_e_r szCxnepTt ► I( our m<. S <br /> tno-�ed : �u c� uses l�unA, /Sr11rnri,r i-s r r e-r <br /> nnUiC,c ur __-Mley e d -tares CAre- CEc fn K n , <br /> t6l is <br /> al,cz nn_s��re. . All -ares are rn <br /> ie6tlon Dorm nc u e . <br /> Comments Included: Q Rs- -- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Numbe' <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X i r_X A "Al P I L I El 12 E3 62081 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />