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ns ection Report Number <br /> � Waste Tire Suy & Inspection Report p_- ---__p <br /> Californiaa State of BCalifornia - - <br /> G'1 <br /> Cgrated asteManage Survey Form - Page 1 1 7 - 110 1 3 7 7 <br /> Integrated Waste Management Board — _- -- -. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- inspection Type (Fill one) <br /> Site Suffix: ` 1,� 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> --- ........_.....--- <br /> Local J If Referral,choose referral type(Fill one) <br /> Identifier: �f� Q CHP 0 CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name --- <br /> Inspected By Inspector <br /> Physi al Address — � ` 1 L- �;+ ! yf k ( 41 iI t <br /> Street <br /> Inspection Date / II <br /> 'fir � � 1 � _� i•� j(/- m l l �� l t_� <br /> City u- uState ZIP Code) Time In Time Out d <br /> Business Rep Title <br /> • <br /> O AM ,Z O AM <br /> r 1 t Irl t i 0 PM ) V 1 0 PM <br /> 1 r Operational Status Tire ( Business Rolet age Type <br /> Tire Count(WhOlelPtE) (Fill one only) (Fill ill t )ws %- (Fill all that apply) (Fill all that apply) <br /> k q <br /> Q Active 0 Pc �f r r Q Generator 0 Outdoor <br /> „ r <br /> O 0 Closed 0 Alf r r,i" <br /> � � <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 Inactive <br /> Longitude - O r("t ' <br /> g 0 Planned 0 <br /> OTR <br /> 0 End-Use 0 Container <br /> Lousiness Type (Fill all that a�pl;r , 7,wL,,., <br /> 1 <br /> L1W,_, <br /> 0 New Tire Dealer 0 Auto Repair Q 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 j A HAULING AND MANIFEST REQUIREMENTS <br /> - - - 0 Notice Of Violation 0 Extension I <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 <br /> M / m / FF] <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 /> i <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 <br /> 0 In Compliance - No Violations <br /> 0 0 !Other: <br /> Comments J ./ ( % { t 4 <br /> ;� ''04 f L_o. i' - - - t > l — ((- _ _)_�— ;l <br /> Ji f l:/ i(V1L.1 tf)lf �_ �` + /' il_ �U✓l ! )//I1lif) �.ri� �=3� � )� �; �., r �.` ,. <br /> (,.�i t/ `� J `1� I.. � � r-,-F'✓: ./ l(Jf i' `�� !' 1 f 1 :l f.' r;�i/( � <br /> rt •,1 ! fit at <br /> Inspection Form Included: 0 <br /> Comments Included: - <br /> 0 Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X /P \/ . 141, !. 1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />