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f <br /> f <br /> Waste Tire SL & Inspection Re ort Inspection Report Number ■ <br /> ■ f�-::. - Y p p <br /> 6ma a State B California Survey Form - Page 1 I 1 - 10881-169 <br /> CIWMB 181(New nage Y <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile! ) ` "% Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ,3 i �' 3 ] 7 0�- Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S )n jG Ct U i r C o U n <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business-or Facility Name <br /> Inspected B <br /> p y Inspector <br /> 1 I - L m �Lu�.-r <br /> -� v CAU t Y) L A me r <br /> L- I <br /> Physical Address �---�-- �-� i q ' Q � kr l ticr) 5 <br /> II <br /> L ilii 111 _ <br /> -- - _ <br /> Inspection Date <br /> S`fi o C1-A-cm C.A 9 520_3 i <br /> State ZIP Code Time In Time Out <br /> Business Rep Title —� OAM [7] Q AM <br /> cc 0PIM 0 P <br /> _Mb �f t�'L r r�_�, r_�. <br /> Operational Status Tire Type <br /> Business Role Siorage Type <br /> (Fill one only) (Fill all that apply) <br /> (Fill all that aPPIY) (Fill all that aPP!)') <br /> F' ® Active Q Passenger ® Generator Q Outdoor <br /> �O Q Closed Q Altered <br /> GPS Latitude —� Q Hauler Q Indoor <br /> Inactive 0 Truck <br /> LongitudeQ Planned Q O?-R <br /> - Q End-Use Q Container <br /> Business Type (Fill all Lhat apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 11� <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other I L U r­.UC r `r'nr� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 'I HAULING AND MANIFEST REQUIREMENTS-- - - - - - - _- - <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> 010 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q I Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § - <br /> Comments <br /> 1KoutIR.Q_ In'fig ctt!�+� nQr oror cl -th1� c6ctt� -t4�e oli0r;crhe*l : <br /> ►=CiC 'A S u -Tire or__ ;,ia��e � 'ir fe-r,aoycA F1DT mant <br /> ar,vC �JCe r\ C a_yCA1 )�Qc l l )2YtL raY Ci 1, (7, C :6r vlewl n on r 'C?f I!.._2+ ..._ _ Njo r t <br /> rt! <br /> inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature -- Phone Number InsSeCfror's Signature r - Phone Number <br /> V .F _ q ° 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X )Y <br /> �. �, A Aral P I_:E .L t9 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />