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Inspection Report Number <br /> Waste Tire606y & Inspection Re*to _ � <br /> ,State of California w <br /> � c ! - i � ! <br /> ;;CI11VM6181(New 04104) Survey Form - Page 1 <br /> California ln�te�rated Waste Management Board ! • <br /> Part A- Survi ; _ BLUE OR BLACK INK PEN <br /> rr <br /> �,y� u u rrr r i t rk <br /> i <br /> 1� r R^rzF rr w r r r H <br /> _ ,- tt '' ' b �Y176k�_a <br /> TPID L r— Inspection Type (Fill one) <br /> Site Suffix: <br /> Routine O Re-inspection O Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 15- r .�'r l.� <br /> c Q CHP Q CIWMB Complaint Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> / - - d 1 <br /> �_�____� <br /> Physical Address <br /> Street <br /> Inspection Date LL l �JI <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title d . [__F O pM116A dr—, <br /> (4AM <br /> L L_':_R " I O PM <br /> Operational StatusN t ', ; ¢ Business Role <br /> ,rah l •W'2Y <br /> o� (Fill one only) a @� .p (Fill all that apply)Ul <br /> ® Active �J (4 Generatorw�,r�y�q �; <br /> Latitude C Q Closed <br /> GPS f+; ? Hauler <br /> Li- <br /> _ 0 Inactive <br /> Yy��a, �:,�'�`f �yr��ar �d,�r�;�,�'� �• �„°���i��i a; <br /> Longitude z'.• 0 Planned re'fr) O End-Use <br /> �[$�' ��/'*,�,��x"+ <br /> krn �r <br /> i ^.�tt�ItII. r.,,,.,, - l r.., h aix•r !, ;„.«rw". ,"�z..,it u r : +. .. : . �. ... l •..r w ,..w..w h <br /> �.��"'�,�u.�tr�w�'t��:�"�i'+f� <br /> Q New Tire Dealer O Auto Repair O Trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> Q Service Station 0 Hauler O Agriculture Q Shredder Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation; 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m , 11:1 o <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> IE <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 In Compliance - No Violations <br /> 0 ' 0 Other: § <br /> Comments <br /> F E <br /> Inspection Form Included 0 .✓„w,"+hr°tfa, G: � 04y <br /> MFnf"rya,✓~W ,$a;a'raNa ''�"r, '$"4^$:4""✓'at,l.M aaa+t a� <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X _;, , ,�Y,,. I_ N. I L ; 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> ti <br />