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Waste Tire Su & Inspection Reporspection Report Number ■ <br /> wa <br /> State of California <br /> CIW <br /> MB grated 1(New Manage) S-unfey_Form - Page 1 1 5-_- 1 0 3 3 1 0 <br /> California Integrated Waste Management Board ,_ _ <br /> Part A- SurveyBL BLACK INK PE <br /> v <br /> Business Profile Ins ectt 1F � �� ) R C N <br /> .. � ;.. <br /> p � <br /> TPID- Inspection I - �_ + Inspection Type (Fill one) <br /> Site Suffix: j 2 J��� r'J (? fl <br /> 7 � r: d ( Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Oth <br /> - _ f Q er <br /> Business or Facility Name t - <br /> Inspected By Inspector <br /> Physical f <br /> L <br /> y Address <br /> ,y <br /> Street <br /> Inspection Date <br /> State ZIP Code Time In Time Out <br /> Business Rep Title I�� . O PM 0PM <br /> � <br /> Q AM <br /> W ' � <br /> '— C�r c 1j - 1 <br /> Operational Status Is1(�, *si"eft, Business Role Storage Type <br /> riwist9 YP I <br /> (Fill one only) )�t �t (Fill all that apply) (Fill all that apply) <br /> The Count WhotelP�'E �� fi �r� <br /> Active � � ' �� (D Generator Q Outdoor <br /> HUMMI <br /> GPS" O Latitude Q Closed � � �t� <br /> Q Hauler Q Indoor <br /> Q Inactive r �r <br /> Longitude Q <br /> Planned <br /> st' � Q End Use C6ntalner <br /> i w s wr� s <br /> _�-.u..0"..�A �_-u...�, .,�.,�.s�ed�. ,.+,.,�u3�e �a�,. .,.....��,9� '�c:^�'e"� �.���,v��'!h� �G�,�[l�k�t.�,Y�'�..p "" �e�.,.�'`�,°.�"...,ti" .V��":5..�'n:rk' .a�,��°���i'+nm'✓�`d�M .'�m�m'�a„�'o .�'�� <br /> vQ New Tire Dealer Q Auto Repairs 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> QV QA PR U§NG ANb 11�IAN1 FESTIR RCegistRrat on�endTransport 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 Vehiclb, <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 (a)(N(c)-Tire Program ID I4umber 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 lire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Re�istered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste T*@ End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers"Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments `. <br /> Inspection Form Included: Q' <br /> Comments Included: Q <br /> Business Rep"s Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X 62081 <br /> 'A, <br /> ■ J :..ter <br /> White Copy:CIWMB Yellow Copy:Operator Pink nk Copy:LEA <br />