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Waste Tire SAS; y & Inspection Repo.* Inspection Report Number <br /> gM <br /> StatcIWB Cali181 fornia y - ■ <br /> California Integrated d Was ee <br /> Surve Page 1 jV�Management Board _ <br /> e04/04) <br /> Form <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> S� 'r � 5+4 �'��� <br /> TPID- "Inspectionr_1 r- Type (Fill one) <br /> Site Suffix. (o Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: t h} OCA y\ I 1\j 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - - <br /> r Inspected By Inspector <br /> Physical Address ( [Tc k t i f Z <br /> - <br /> Street <br /> ^, Inspection DateE <br /> �. <br /> (--- -- - -� �% i <br /> City State- ZIP Code Time In Time Out <br /> Business Rep Title 0 AMAM <br /> Imo, C r� 1 0PM � �� 0PM <br /> t r bt� ,�l Ca lt� Gt✓lUf - <br /> rr Operational Status a y Business Role <br /> Fill( one only) " (Fill all that apply) r �" <br /> " <br /> Active " r r &Generator <br /> GPS Latitude O 0 Closed <br /> I I <br /> rrr`; of � 0 Hauler <br /> Oinactive <br /> t a to <br /> Inactivet� <br /> 0 � : <br /> Longitude 0 Planned 0 End Use � t, <br /> 0 New Tire Dealer Auto Repair 0 Trucking Fleet Government 0 Retreader 0 Dismantler Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> I <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility i ENFORCEMENT STATUS 1 <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements i 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 <br /> - - - <br /> I , <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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators _ — <br /> �" ,n Compliance - Na Violations <br /> 0 Other: § <br /> Comments <br /> /4(i <br /> X , !_t '� k !. 50- ( f / GCI Gl'1 I� C' vJ- -' t - <br /> Sha �f%'i�'-.f, � '. Y1ctnifi <br /> �,�� <br /> I <br /> V,J <br /> � f � <br /> 91 <br /> Inspection Form Included: Q <br /> Comments Included: - <br /> Business Rep's Signature Phone Number InspectorsSignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X A , } j I L u, <br /> 62081 <br /> ■ ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />