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ns ection Report Number <br /> Waste Tire Sur 'y & Inspection Report - p - p - <br /> +uu3S,c' State of California "s fI �' gi r <br /> �rnia Cgrated Waste <br /> Survey Form - Page 1 ' BLUEcOR BLACK INK <br /> California Integrated Waste Management Board - <br /> Part A Surve PEN <br /> — <br /> TPID- Inspection Type (Fill one) <br />} Site Suffix: Routine Q Re-inspection Q Referral Q Observation <br /> Local - If Referral,choose referral type(Fill one) <br /> Identifier: ) ; 1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l Inspected By Inspector <br /> -------------- <br /> Physical Address y--� - L r l •, <br /> ------- <br /> 15 <br /> i <br /> Street Inspection Date �� (; f <br /> t_•_��: .] 5fate Z/P d Time In Time Out <br /> City ------ <br /> Business Rep Title ff O'AM AM <br /> 0 _E] <br /> PM FU : L 0 PM <br /> H 3) rpt. ��_�_.'._ <br /> �I Operational Status ) Business <br /> Role <br /> ' ypi M <br /> (Fill one only) (,,t�. (Fill all that apply) (Fill atl thet apps ) <br /> ® ActiveGenerator (Q.Outdaar <br /> D Q Closed Q Alteretl " <br /> GPS or, <br /> Latitude µ ^�� O Hauler <br /> J_ Q Indo <br /> _ _ llo O Inactive 0 Truck <br /> Longitude - Planned OTR Q End Use Container <br /> Business Type (Fill all that apply) _ _"T _ _ -- . _ <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government O Retreader - Q Dismantler Q Tire Derived Fuel <br /> O 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 /> 'i Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> QO 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m17 <br /> Q 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Referred CIWMB Enforcement <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> O Q Other: <br /> Comments IYI1 <br /> f - — - - - <br /> f q <br /> A d � I / F <br /> Inspection Form Included: Q4 AI <br /> Comments Included: O, a - - __.._ _._ �• <br /> B isrness Rept Signature Phone Number rlspec r s Signature Phone Number <br /> - - — _ _ <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X <br /> ■ White Copy:CIWMB Yellow,Copy:Operator Pink Copy:LEA ® ■ <br /> I <br />