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Waste Tire S0416y & Inspection Re orlp! <br /> nspection Report <br /> eport Numb <br /> er <br /> State of Californiali0u-iaCIWMB t81 ew 04/04) - o ® a ( L <br /> California Intgrat dWaseManagementBoard Survey Form Page 1 <br /> Part A- Surve�- BLUE OR BLACK INK PEN <br /> Inspection <br /> B PID ess ..m-u -'Inspection TYpeil(Fill one) <br /> Site Suffix: 1 2 f I Routine Q Re-inspection Q Referral Observation <br /> D 1 <br /> o Q U I n Cou n� If Referral,choose referral type(Fill one) <br /> Identifier: { 111 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Local sort T <br /> Business or Facility Name Inspected By Inspector <br /> Y a n d e-11 Ty- c kca uua enc <br /> Physical Address �� <br /> i i-f 00 �j v a tGd 1,:-;,dam.__ <br /> Street <br /> Inspection Date M b 2 O <br /> L-T CAG S 7 <br /> — _ In Time Out <br /> State <br /> Time <br /> Li ate ZIP Code -. ..—_ —. <br /> Business Rep Title ®AM0 AM <br /> j <br /> O PM ._ - _.L .. O PM <br /> i G h.ESte r Operational Status Tire Type. -�:' Business Role `Storage Type <br /> 1 (Fill one only) (Fill all that apply); (Fill all that apply) (Fill all that apply)' <br /> d Active Q Passenger ® Generator Q Outdoor <br /> t7 Q Closed Q Altered <br /> GPS LatitudeE17- <br /> Q Hauler Q Indoor <br /> -_ — O O <br /> Inactive 0 Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> III ,ww - <br /> Busines Type'°� itl all th <br /> New Tire Dealer er Q Auto Repair ® 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 <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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I 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 In Compliance - No Violations <br /> O Q Other: § <br /> F O�,ne "fit►o n 1[o o t - 4#`� � i I j l� <br /> Comments <br /> No utas e ��res- s-�oreca c,n-�Ite ct -T uc- ire- Svc - <br /> c�r uJct�-_t<_ +Ire- rerr w at . I T t nf,.n Ae5'C5 en y _:fG1_�ed <br /> ay _�� �I. a►' y to wInA �or�- r ,� , -_ �i,., y I�_:1 �' �� ��ri� _ <br /> T_ <br /> .Inspection Farm Included: Q <br /> Comments Included: <br /> Q,Business Rep's Signature Phone Number In -s Signature shone Itu Baer <br /> - .: 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X .E E A M P; l i L� 11 , 2j3 <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />