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Waste Tire Su i & Inspection Reportftspection Report Number <br /> State of California <br /> - -- <br /> arnia <br /> CIWMB <br /> Waste <br /> eMana14) Survey Form - Page 1 R 8 - 1 01 a 3 l 9 <br /> California Integrated Waste Management Board <br /> Part A Surve BLUE OR BLACK INK PEN <br /> r-- <br /> t <br /> 45.4._,nrr'�, V I• u 0 u ct 3..`` Y�", .N.'r ;r„'.:r.n'ci�ac' ,d'''„ � " T5��4,5'1r"�r r r � ^r,rs )" I "^r " ww� �„`r ""«r G4 a :: ", av^5,/y%r';! <br /> �_a, .n�%��l,: ..r✓�N..,,.r 3�.. _.__,.....�,!:. ":_pt..">'�J <br /> TSite Suffix:PID- J --- Inspection Type (Fill one)7z, 7-,7, <br /> nt ,­ - ��� <br /> . I (D Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: CHP CIWMB Complaint 0 0 0 P 0 Educational Visit 0 Other <br /> Business or Facility:Name — aY <br /> Inspected By Inspector <br /> Physical Address <br /> 7' <br /> Street <br /> Inspection Date <br /> Cry �State ZIP Code) Time In Time Out <br /> Business Rep Title <br /> Q AM Q AM <br /> QPM � ' C� QPM <br /> z Operational Status Tire Type Business Role �� �" <br /> *; <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) tal)'l� lttrl r <br /> t t t Active 0 Passenger 0 Generator <br /> ut <br /> - <br /> Latitude D 0 Closed 0 Altered awe ` t <br /> GPS T_j_T] <br /> 0 Hauler <br /> 0 Inactive 0 Truck <br /> 41 <br /> O Y fiat f )� f r <br /> Longitude 0 0 End Use r r Planned 0 OTR <br /> t2,ed <br /> s Type (Fill allthat apply tt._0Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Tire Dealer 0 Auto Body- 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> Service Station Hauler <br /> 0 0 0 Agriculture 0 Shredder 0 Other l <br /> P�' rt A iInspection of Waste Tire Dealer,HAULING AND MANIFEST REQUIREMENTStor, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - - 0 Notice Of Violation 0 Extension <br /> 0- 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> ' 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date IM / Ell <br /> / .m <br /> 0 14 CCR§18459.1 (a)(b)(c) Tire Program ID Number from CIWMB <br /> 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> (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 /> 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> -- <br /> Inspection Form Included: 0' -- <br /> Colrements included: _ <br /> 0,Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X ; A 1.0. ,D I_ - <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />