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Waste Tire SC'Oley & Inspection Reporo Inspection Report Number ■ <br /> State of California / - - - ------ . <br /> �r Cgrated Waste <br /> eManag) Survey Form - Page 1 , 1 6­ 71­ 0­1­0 6 1 4 <br /> California Integrated Waste Management Board - - ---- -- --1 - <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> 16,�1SIp�''S ,�� p � ,�CF't�ad" ���5h 1�'��,�>t�P�, ���1����� " "" ... ✓ r <br /> TPID- Inspection Type (Fill one) <br />} Site Suffix: <br /> / V ® Routine Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ,( wl oq "_(,t;k.t'1, t.. ii(,t_y", ^ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name } <br /> Inspected By Inspector <br /> Physical Address <br /> � <br /> 1L* <br /> ( Vl ow vi <br /> Street Inspection Date <br /> KA <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AMAM <br /> vj PAY I-.-- � PM � ' � QPM <br /> r <br /> I `J Operational Status Business Role <br /> ( y) t �;L � m ( ( apply) <br /> Fill one only) ti Fill all that a I <br /> Active (jo GeneratorNINE= <br /> 0 0 Closed <br /> GPS <br /> Latitude �� . "h t, �, r ��a�` i r ""�� <br /> r Mei rlhvl'"n.�flH° " v Hauler �✓« 4, Ct"X�,Pq " r <br /> r7 r rrv "9ti r <br /> _LI I <br /> 0 Inactive <br /> Longitude �ir arri0 End-Use0 Planned `� F�l�eft rr <br /> �,. <br /> 0 New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 0 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 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 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 0 In Compliance - No Violations <br /> 0 0 Other: § _ - <br /> Commentsr <br /> r.l c't l f �.� <br /> r - <br /> 1 �r� 1��t V�,�� �E r. `�c�c�� �. � , ( �1-i f r ; ►v� t i I- <br /> T }lir fr � h C71!), r /� f/ ✓� li it /;a ( -t / G, f :1 ��t 1�r +^ i <br /> Inspection Form Included: 0 <br /> Comments Included: 0 _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® incorrect: X <br /> _ 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />