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Waste Tire Su Y pReport& Ins ection nspection Report Number <br /> ® <br /> arnState B California I 1 - 1088011 <br /> ia CIWMB 181(New Manage) Survey Form - Page 1 <br /> CahforniaIntegrated WasteManagementBoard - - - - - <br /> Part A- Survey T BLUE OR BLACK INK PEN <br /> -- . T _ <br /> Ins ection Details " <br /> Bu�ness Profile 1 — p <br /> TPID- 3 2 LI 6 - r ' Inspection Type (Fill one) <br /> Site Suffix: II v I ® Routine Q Re-inspection Q Referral Q Observation <br /> I <br /> Local , r. If Referral,choose referral type(Fill one) <br /> Identifier: --To G C t-1 t r( GO U(l{ <br /> >' 'Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ----— -� -I 0=1 <br /> Street <br /> ` �3 � J_71 ,LYL& <br /> Inspection Date <br /> t- <br /> �-- _ _ n _�_ GA 9— __----j <br /> City State Zl- f;ocie Time In Time Out E <br /> _._ _— <br /> Business Rep Title O AM O AM <br /> 0 P 0 P <br /> rt Cln-e ....a �-- <br /> y -- - —r Operational Status Tire Type Business Role Storage Type <br /> Fill one only) Fill all that a I (Fill all that apply) (Fill all that apply) <br /> '777 <br /> ( Y) ( PP Y) <br /> ® Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> . O Q Inactive Q Truck <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> - <br /> Business Type (Fill all that 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 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 Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB I <br /> Q Q (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q O -- --- - -- -- <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 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 /> QIP - - <br /> Other: § _....._.... .... . .......--..-. .-_..�.__—_,.—.�_._`r <br /> Comments ((� (( 1 <br /> U v.� ' -TCS`( UtC. <br /> FaOlkq LA,SeS Y_- r,cAnnon _T►r-� Scor -�Nre _ serdl c2 'feMOVg� , L,0__af4 a r - <br /> -��e� 1- a�ar�or6\lzcl C.n scr�v,r : c.< -fi'I ares removed ,)n <br /> rl , 61r ,� l �- � � a� fie. Trvn�r �l �_,.�)tC� No �jiotcxi* ov Cfreq o <br /> ------ <br /> inspection Form Included: <br /> Q <br /> Comments 4nc9uded. <br /> ' <br /> rk, <br /> Business Re Signature Phone Number Signature- I pevEor s Signature„ ; +y t"������s.hz Phone Number i <br /> - _ <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: A�, 1 V .� A M P3 62081{ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />