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Waste Tire Sur .y & Inspection Report Inspection Report Number' <br />State CrWM f 81lNew Survey Form Page 1 1 8.1 0 13 4 4 5 <br />CIWMB 181 thew 04!04) � <br />California Integrated Waste Management Board <br />cta.f e _ crrrucv BLUE OR BLACK INK PEN <br />Business Profile �6 <br />Inspection Details <br />TPID - <br />Is I ijA 9 (� I <br />Inspection Type (Fil I one) <br />Site Suffix: 11' D <br />O Routine Q F e -inspection Q Referral Q Observation <br />If Referral, choose rf ferral type (Fill one) <br />Q Visit Q Other <br />Local <br />Identifier: <br />n <br />JG2t? �/04�--. C.� <br />Q CHP Q C1Wl1B Q Complaint Educational <br />Business or Facility Name o_ <br />Inspected By Inspector <br />9L - <br />Ulil - C I�Z <br />Physical Address <br />Street <br />Inspection Date <br />p y 1 O I D 6 <br />S4� <br />City State ZIP Code <br />Business Rep Title <br />Time In Time Out <br />0 Am <br />+ 0 PM <br />: C'1�] <br />[/Z <br />PM f <br />Operational Status <br />Tiirre Type <br />Business Role <br />Storage Type . <br />The Count (Whole/PTE) <br />I <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />r <br />® Active <br />Q Closed <br />Passenger <br />Q Altered <br />Generator <br />Q Hauler <br />Q Outdoor <br />indoor <br />j I <br />GPS Latitude 1 <br />Lp <br />O <br />- ^� -�� _;L____ll <br />—r- �Longitude - ; � <br />Q Inactive <br />Q Planned <br />Q Truck <br />Q OTR <br />Q End Use <br />Q Container <br />-I <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreadt:r Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb F ubber <br />Q Service Station Q Hauler Q Agriculture Q Shredder Q Other L I <br />Part B;. Inspection of Waste Tire Dealer, Generator, Hauler and End -Use FaHlity <br />ENFORCEMENT STATUS <br />V HAULING AND MANIFEST REQUIREMENTS <br />Q Notice Of Violation Q Extension <br />Q PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q Q 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date <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 <br />(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 <br />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 Genera tors <br />• In Compliance No Violations <br />Q Q Other: § — <br />Comments gQC,C,,te_Q <br />/-!tjjJJJ -�i�K '_i <br />/G�c/ <br />rte^ <br />lam/ OCQX�►. / QirI LAr!'}� i/v �• G d'� "f"� %•'? Qi�. <br />a'v,!c� �o Gum�1 _Su tam y{-ua.`t�+ 21- ,E�i118roL wa-j <br />Inspection Form Included: Q <br />! I II / ,(`� r �` / / /' <br />�P 4.9 -U3 38 <br />Comments Included: <br />Business Rep's sianature Phone Number Insl sector's Signature Phone Number <br />62081 <br />INSTRUCTIONS ON BACK Correct: Incorrect: :=&Rr E RAIMIPILIE1 <br />White Copy: CIWMB Yellow Copy: Operator Pit k Copy: LEA <br />