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1 - Waste Tire Suoy & Inspection Report• Inspection Report Number <br /> State of CaliforniaCIWMB 04/04) <br /> �r} �/�1 4 t `j''� <br /> California Int grat dt81 Was eeManagement Board Survey Form - Page 1 V 10 3 5 5 8 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- , n I - r� Inspection Type (Fill one) <br /> Site Suffix: <br /> Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localf If Referral,choose referral type(Fill one) <br /> Identifier: �( v1I 0 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> Physical AddressE !.` <br /> Street <br /> i t Inspection Date <' <br /> Citi y — State Zip Code Time In Time Out <br /> Re 0 AM <br /> p Title . _L I� PM L�_.�,_.__ E,- <br /> Business <br /> PM <br /> 1 I <br /> int (? j/(61 t j Q' � t , - <br /> "to Business Role <br /> � r Operational Status�+ , w YI "" � ,'� <br /> (Fill one only) I�� � "��� (Fdl all that aPPly) <br /> ,f r ,"� " � illa�f1' <br /> ti <br /> � n l i raw p.,iralJ x) r r;+u'mW <br /> Active r Generator <br /> .ice. ...nm <br /> ® v"'� '�ili „";, ;.. <br /> d E6i /a iM Wr rk t <br /> 0 Closed <br /> GPS Latitude Ll - Li-ii- <br /> 0 Hauler <br /> OOlnactive f�'���'��rtr� "�. a�0 <br /> Longitude - � 0 Planned +/a f 0 End-Use <br /> "BUsir efxII - <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 Other R 'ILI <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> --- <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <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 0 In Compliance - No Violations <br /> 0 0 Other: § _ <br /> Comments llAJ]11�.(. (/� Ct; ;'� fi� 1v1,.( C r f�4 lJf�tl/J(.'✓ t '',1.f el � f ( ` e <br /> f <br /> of 0, f 'LF`� f� t �( �i/_� C 6o v l o. U Je - <br /> �'(4!'Lf:lc'r. . -4? ! ,4, /r' Lf T( )✓(1''� �r �'j 1: f c =< I i C (, h rp '0/ <br /> �t � r- <br /> Inspection Form Included; 0, <br /> Comments Included: 0 - - - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X 14 A14 i 62081 <br /> ■ __.. <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />