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Ins ection Report Number <br /> dWaste Tire S.ue & Ins ection,Re or p p Me,;',teManage Survey Form - Page1 1 4- 1Qt0 6 64 3 <br /> CaliforniaifIntegrated Waste Mana ement Board <br /> Part A Survey BLUE OR BLACK INK PEN <br /> �InS ectlDn <br /> 21 <br /> TPID- _ v Inspection Type (Fill one) <br /> Site Suffix: <br /> ` @ Routine Q Re-inspection Q Referral Q Observation <br /> ------ ..— <br /> ------------- <br /> > ' ' J'v;4 vti 1 If Referral,choose referral type(Fill one) <br /> Local i �— _1 � <br /> Identifier: �. ,ut Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address �.F <br /> Lk <br /> 1.i <br /> 1 -J <br /> Street <br /> Inspection Date <br /> City State ZIP Code <br /> Time In Time Out <br /> Business Re _ <br /> AM � AM <br /> C3 Title J � <br /> �. <br /> PM <br /> 111�1 t_ ' ® PM <br /> Rep <br /> is Operational Status itw t"; P `w` �� Business Role <br /> ji <br /> _ (Fill one only) (Fill all that apply) <br /> LOA <br /> Q Active Generator i'Qttwa` c <br /> F <br /> Q Closed i��t "��rrtr��Y�„„I✓;�v t'rwer N <br /> GPS Latitude Q Hauler <br /> QInaCtlVe <br /> wsFriri <br /> r+ <br /> Iw w Itr yr 7 eF �S y 6a� ,$, <br /> 0 t^���wr�`"�✓,4rr�zW���rl s. i/aS��rw"t`��rA��� C�i"^r <br /> , Po t,�wdrrF( 1 Q End-Use Q Planned z" §r <br /> fit f 7Vw5 <br /> 11 ol <br /> J <br /> 1 ..- „I � .� v/W� •�+,«��°� rr•6,„ v t ., ,.,,, ',ern, <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 �, t -'t" <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 (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!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 Q In Compliance - No Violations <br /> Q Q Other: <br /> Comments <br /> i <br /> Inspection Form included: Q <br /> Comments Included: Q - - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X _ �;i 0tiq w' _ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />