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<br /> Waste Tire Sur* & Inspection Report -p- -- _Report-_ _ _ -_
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<br /> RRR £R State of California ij�
<br /> California Integrated WasNe Management Board Survey Form - Page 1 _ ( 1 - 1 0 -� ,� 1
<br /> 1 7_ ,I
<br /> Part A- SurveyBLUE OR BLACK INK PENP "ERE1
<br /> TPID- I Inspection Type (Fill one)
<br /> Site Suffix: , r; v /
<br /> � f✓ � ®`•Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier:
<br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name { — -
<br /> Inspected By Inspector
<br /> I
<br /> Ph ss ca'I Address
<br /> Stree( I
<br /> Inspection Date A
<br /> City State ZIP Code Time In Time Out
<br /> Business Rep Title E : O PM Fj] : CE O AM
<br /> PM��.
<br /> -
<br /> -� ! Operational Status Business Role
<br /> r „diy,,irk qpm f
<br /> (Fill one only) �OtfiL) pl (Fill all that apply)
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<br /> �,, n�
<br /> Active r �� Generator '� �r �s
<br /> _
<br /> 70 0 Closed p
<br /> GPS Latitude 0 Hauler
<br /> 0 Inactive
<br /> Longitude — t tm 0 End-Use
<br /> 0 Planned
<br /> M«" " l Y� ) dl N
<br /> "r i9t^M'1 / l t�* ' l 0*x^ a " ���",..u�,,,..... —�.,.u,.,..,..�. .,5�.,.,..._✓1 �., lln`Q ., d '�� _., l �...x� ,r.. .,�, Y,
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<br /> i ,�" e,„�,s[ '� i d ��:1.�?�.✓ ll� h�rl.,.� � �.,.�.
<br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel
<br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber
<br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ' ENFORCEMENT STATUS
<br /> V AHAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension
<br /> I
<br /> 0 0PRC§42951 Waste Tire Hauler Registration and Transport of Tires
<br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> 0 0 PRC§42956-Registration/Decal in Vehicle
<br /> 0 I 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m m m
<br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT)
<br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years
<br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement
<br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators
<br /> In Compliance - No Violations
<br /> 0 0 Other: §
<br /> Comments ±
<br /> J {
<br /> Inspectiq
<br /> � 4tip; ',m���f�s "' M c�t. '�%d�i�" `�h l,�r'' ,w�F✓�. .,� ,��^6.lrr �,,,,�t��,"a"��u�:'" �tr�r.,��k����v 2rn5;"."Ir,;`�ll+ ���'�?, rwlrt�`�k"u f X% �c,�� ++r�:, �iu^ ' ' ��'rl rv6 w""f� ra"�
<br /> Comments Included: 0
<br /> Business Rep's Signature Phone Number Inspector"s�Signature ,Phone Number �I
<br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X i,—�, ,tri' I f 4N Wbµ `� L I
<br /> 62081
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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