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Waste Tire Su y0 Inspection Repor Irl. tion Report Numher <br /> State of California �{` �/�j Ij� <br /> 04/04) <br /> California Int grat dCWMB181 Was eeManagement Board Survey Form Page 1 ( 10 2 5 8 9 6 -� <br /> Part A Survey " BLUE OR BLACK INK PEN <br /> r ;rw r -' <br /> rn?' Nl r r^ Gam, +'�'x m,r c a r•r r +f'd'Y /"f:2 d n r�, �". r ri r,..a <br /> � i�t�rr(, <br /> � r� �t„,..�/ "rv .,.u..✓.rf;,�,a..,r � <br /> �a�' ,.,. _ n,�., a rpr„ r._..�:".fe,t ..�, .�—.—.��.r�G,HTI_v.,,rd NrS.,�.!�..1"�w..9�;r.....v.,. ✓�:�.,''' .,,.f•N.�, <br />} TPID- inspection ection T' a Fill one <br /> Site Suffix: (4 Routine Q Re-inspection Q Referral Q Observation <br /> Local 7L, <br /> If Referral,choose referral type(Fill one) <br /> Identifier: 1 on. ,1 �� Q CHP Q CIWMB Q Complaint Q Educational Visit, Q Other' <br /> Business or Facility Name ( - - <br /> Inspected By Inspector <br /> Physical Address <br /> Street _ <br /> L `,>C 0A �r. Inspection Date ( } �� / �✓ / l r C <br /> � i�- i��Z7 iif .� ���I V lJ J <br /> City State Zip Code Time In_ Time Out <br /> Business Rep Title l Q AM Q AM <br /> ClL X ►�GJ �fclw�- <br /> �_�_.� �0 PM - � 0 PM <br /> I Operational Status f Nei � > rPT Business Role Storage Type <br /> �— ffl (Fill one only) (PII(r'�I�� �M+ (Fill all that apply) (Fill all that� apply) <br /> r <br /> (&Active Q Generator Q Outdoor <br /> Q r rrr3r� dnr p <br /> Q <br /> Latitude Closed i )w <br /> GPS `� ® Hauler Q indoor <br /> — — _ Q Inactive �3r"a )° <br /> Longitude - Q Planned Q pTR Q End-Use Q Contalnt i <br /> Business Type (Fill alt 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 t _Hauler Q Agriculture 4 Shredder Other y, <br /> r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A j HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation O Extension <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 F11 m l 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 clays (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 D 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 <br /> Q In Compliance - No Violations <br /> Q Q Other: §L -- <br /> Comments ; <br /> t <br /> — --. £ ,' avcl _—fr _ I1.�. �, { ��GtvtlN,': VV1 < ( ;nZfu(_tC)f' GIi<I <br /> (O(VI 01*I�t(.0 bfed LY C(4S) V,C4 W iA r�t 4 1, ii jir <br /> i , r c''" vt1 R C'ct l artl rrrP`> � Y1 Q¢t� �o P_ 00 w 0 ) .. <br /> inspection Form Included. QI <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ <br /> ® 62081 <br /> INSTRUCTIONS ON BACK CorrectV Incorrect: X �X,A M,-ii <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />