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Inspection Report Number <br /> Waste Tire Suay & Inspection Report! ■ <br /> ffai State of California <br /> Cgrated asteMana a Survey Form - Page 1 f - 01111342 1 <br /> California Integrated Waste Management Board -- - ----<< - <br /> Part A- Survev BLUE OR BLACK INK PEN <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: J. (1 rl �{ (;, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> i I f Inspected By Inspector <br /> Physical Address <br /> < : � <br /> Street <br /> t � Inspection Date /'1 /I RE <br /> Time In Time Out <br /> City State ZIP Code _ _ <br /> Business Rep Title t� L <br /> – O AMJ� 6 O AM <br /> 0 PM 0 PM <br /> ,f 1. (t( � Gt,�Y�F {� I – <br /> 1 L <br /> L Ir) Operational Status ire Type Business Role Storage Type <br /> t <br /> (Fill one only) (Fill all that apq (Fill all that apply) (Fill all that apply) <br /> Y) <br /> QActive Q Passenger <br /> (D, Generator Q Outdoor <br /> D. Q Closed Q Altered <br /> Latitude Hauler Indoor <br /> GPS EE - FJ__—_ Q Inactive Q Truck Q Q <br /> Longitude – I� r� i O Q End-Use Q Container <br /> 9 Q Planned Q OTR <br /> Business Type (Fill all topt apply) <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 /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other 9 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V , A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 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 <br /> FF <br /> / m / FT] <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <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 Y CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> I <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> (Din Compliance - No Violations <br /> Q Q Other: <br /> Comments jCvC`(, (-Lrc( <br /> � V 1 c�f I1 01�_}triv s P } OT1, i � c + � � a (Jrt (o, r -it S 4�C_ S( Ir <br /> if'V i (-`l i ✓'lily <br /> Inspection Form Included: QI <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number/ Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:9 Incorrect: X 62081 <br /> l ,ti �0' :�. H . � . <br /> ■ .' . v fi l I_ Q .t Lr0 l <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />