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■ :.A — - - ■ <br /> Waste The S y 8c Inspection Repor Inspection Report Number <br /> ka <br /> State of California A <br /> CIWMB 181(New <br /> Manage) Survey Form - Page 1 1 - 0 - >~1 Z , 1 <br /> California Integrated Waste Management Board __ ______.,_, <br /> Part <br /> Business Profile Y "�, Inspection Details BLUE OR BLACK INK PENp1 <br /> TPID- I � Lt ✓I ] L <br /> Inspection Type (Fill one) <br /> IL r, <br /> Site Suffix: O Routine O Re-inspection O Referral O Observation <br /> Local j If Referral,choose referral type(Fill one) <br /> Identifier: <br /> <"{7 y t`_y"? 2 " r [ O CHP O CIWMB Q Complaint O Educational Visit O Other <br /> Business or Facility Name — <br /> ,— Inspected By Inspector <br /> y I / <br /> Physical Address <br /> Street <br /> ;y Inspection Date / T I <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title �Q AM Q AM <br /> D_ j <br /> j0PM <br /> [:J] <br /> � QPM <br /> Business Role Storage TypeOperational Status Tire Type <br /> The GOunt (Whole/PTEA (Fill one only) (Fill all that apply} (Fill all that apply) (Fill all that apply) <br /> J O Active 0 Passenger O Generator O Outdoor <br /> l!',?..w�.'.v.'hri,,,i f"i.at <br /> O Closed O Altered <br /> GPS Latitude . I —� 'r ' O Hauler 0 Indoor <br /> tL-- O Inactive 0 Truck' <br /> Longitude — O Planned 0 OTR O End-Use O Container <br /> Susi rM��, voe (r Il all that <br /> O New Tire Dealer Q Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder (5) Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> if A HAULING AND MANIFEST REQUIREMENTS <br /> - — -- O Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m / m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O O Other: § <br /> 1-' <br /> Comments - <br /> f_J J <br /> f i,,._r. i_-_ ' f f l fif ` jro <br /> 1I' ,,/l,d of C'• l( 1/cf` 0 1 f c-(( ✓Il,- o �)L � �"'k � J fr 42/�( f[� 1/ (( �' 41'y� t <br /> JV l t t�. C' ` r`f. f �'t I -tl\,� "yt � t/�C �G\ '✓'7 Y a•Jl �4'�. <br /> ""�I�` �, j f � ` i % { Vii. `, '"(I 7I 1 ) I r,y .. <br /> Inspection Form Included: 0y <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ® <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X _ 62081�/ ,�; I I <br /> ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />