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_: Waste Tire Survey & Inspection Report Inspection R419=6 <br /> N <br /> ,� Stele or lilomla <br /> erolM8 ta,Ca(New04MM4) Survey Form - Page 1 1 3 . 1 0 13 2 0 1 <br /> Califomia lntagr ted Waste Management Board -- <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profileif I �1 1lIlJI _ O } Inspection Details <br /> T �( � Inspection Type (Fill one) <br /> Site Suffix: #Routine 0R <br /> e <br /> - <br /> inspe <br /> ction Q Referral Q <br /> Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Iderttifier: -v�.�zT�[TC t.� ( cxtti�, Q CHP ' Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name y <br /> Inspected By Inspector <br /> L j 14 FoTysical Address Akf� <br /> � <br /> ­7 (" S I - <br /> Inspection Data � � m <br /> e.0 R f3,34I J/Q <br /> Cr��� � State ZfP Code Time In _ Ttma Out <br /> Business Rep Title —ln O AM ELI: Q AM <br /> 'F �PM O PM <br /> _ _—! _ J L _l.c�N. •J Operational Status Tire Type Business Role Storage Type <br /> Tire Couilt--(iiW"hole TE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 I I 0 Active Q Passenger ®Generator 0 Outdoor <br /> Latitude Q Closed Q Altered <br /> i <br /> GPS _I.L _ 1_J _ Q Hauler Q indoor <br /> � r Q Inactive ®Truck <br /> Longitude - I I I + i—I -10 <br /> Q planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair (W 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other L I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENF_OR_C_E_M_ENT STATUS,_ <br /> VI A HAULING AND MANIFEST REQUIREMENTS 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 /> Q 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q if 14 CCR§16462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q 10 1 Other: § <br /> Comments ; 1/�1MM i_ti''a— i!•� —!=�"rL rSlf V""` _V�h <br /> Inspection Form Included:Q <br /> Comments Included: 6 3-:3- <br /> B <br /> �- <br /> B s_ s Signatur Phone Number �nspe or's Signature Py <br /> e <br /> Number <br /> 62081 <br /> INSTRUCTIONS K rect:0 Incorrect: <br /> ■ whit Copy CIWMYellow Copy.Operator Pink Copy.LSA © ■ <br />