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:. <br /> Waste Tire ." s ection Re ort nspection Report Number <br /> p p _ <br /> B�wC&0 State of CaliforniaCWMB 181 04104) <br /> Ji �J{f j/�� �/� j <br /> California Integrated Was eeManagement Board Survey Form - Page 1 1 -1.., 3 - 1 0 0 8 0 8 5 <br /> Part A- Surve _ BLUE OR BLACK INK PEN <br /> ref }(, .... <br /> TPID- r-- Inspection Type (Fill one) <br /> Site Suffix: T Q Routine Q Re-inspection Q Referral Q Observation <br /> IE <br /> ------- <br /> Local 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 /> j <br /> Physical Addresso —'-5-�(J--- --� �- 9 I - E ryl� j l <br /> / <br /> A <br /> Street <br /> Inspection Date <br /> EU <br /> State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> t�1�1 O PM ' 0 PM <br /> i j I - <br /> Operational Status r , r Business Role <br /> r only) Ili Fill one all that apply) <br /> i1 <br /> Y) Fill" � � ( <br /> r,�{sj Q Active �� �x t ��"Iw� Q Generator <br /> - - , <br /> O W� Gn ty � " rutu +a <br /> �+ Latitude Q Closed 1 . r,� ,�t <br /> GPS �� i�a rx"aP� Q HeUler �+( rCQ �° <br /> Q Inactive �a <br /> l a yr i^ rn <br /> Longitude - Q Planned � r( t�"";� Q End-Use 1^ t1Itty„ri <br /> M „ <br /> t #toe Typenl`JC l(ttt <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 @ Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 <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 O 14 CER§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 <br /> o ” <br /> „ <br /> Q Q Other: § <br /> Comments - <br /> '�� (L; '�� l 7 � <br /> \1 U� 4- <br /> Inspection Form Included: Q <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> —" 62081 <br /> M <br /> A INSTRUCTIONS ON BACK Correct:® Incorrect: X <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />