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® : Waste Tire Su y & Inspection Reports.Inspection Repori Number <br /> .r ® State CIWMB 81(New L 1 — 10 414 <br /> grated asteMana a) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> tRMpect)on"Def7i')s <br /> Y` { `\ - <br /> TPID- �' �� Inspection Type (Fill one) <br /> k Site Suffix. � � �' L 4 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local } _ If Referral,choose referral type(Fill one) <br /> Identifier: ( ,� 4 ts /t__ x}11 y. 1{ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name J — <br /> ; `r Inspected By Inspector <br /> j �Physical Address •��� � f <br /> _- r 5_l_� L�12_/IILL �`� r-� <br /> Street p Fd5 Ins ection Date 1 r' <br /> State ZIP CactP Time In— Time Out <br /> Business Rep 3 f f �a AM <br /> p Title 0 PM f [�� <br /> 0 <br /> C —h- PM <br /> ------- — ��"---"'�—_--- ' Operational Status Tire Type I Business Role Storage Type <br /> "'' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that:apply) <br /> Count'Wn,Sle, ( 'I <br /> �� „;-�r; :a �" - %� 0 Active 0 Passenger 0 Generator 0 Outdoor' <br /> „ _ <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> EI - o OF-7-1 <br /> Inactive CTruck <br /> 1F_�I_7 <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 Other f� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 i 0 Notice Of Violation 0 Extension <br /> 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 <br /> M / m m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/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 <br /> 0 In Compliance - No Violations <br /> 0 0 Other <br /> Comments <br /> r' <br /> �l ."� rrJ rC;r - t/(� c�`,lc '(r1 �a titt' for <br /> Inspection Form Included: 0, <br /> Comments Included: 0j ' ._ s"S <br /> Re <br /> I smess p' ignature Phone Number Inspector's Signature Phone Number <br /> _ - _ i- •,� i <br /> �, ��o <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: 62081 <br /> i 1�'A <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />