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Waste Tire S & Inspection Repor' Inspection Report Number <br /> ---- - — ---- <br /> 69u"8Y- State of California <br /> W�r� CIWMB 9 teManage) Survey Form - Page 1 1-_ 5 ---� Q -Q 6 7 9 2 <br /> California Integrated Waste Management Board - _-_.. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- 7 �_ 9 � Inspection Type (Fill one) <br /> Site Suffix: r 5 V Q Routine (t,Re-inspection Q Referral i Q Observation <br /> Local l �7 r� If Referral,choose referral type(Fill one) <br /> Identifier. ! QCa Gt c n 1.-��i it CHP CIWMB Complaint Educational Visit Other <br /> _ ______ _ Q Q Q Q Q <br /> Business or Facility Name <br /> I � Inspected By Inspector <br /> 1�(. C PU /L}�E w, SPY✓I C F '-11 <br /> Physical Address �- <br /> 1C�cre - <br /> Street G 7 Inspection Date r +� <br /> ( )( C 6 i 04 _j �f}�i 1 <br /> City State ZIP Code Time In Time Out <br /> Business Rep ��t q(Q l:qS Title �y O AM (� Q AM <br /> ® <br /> I � PM D t Q PM <br /> Operational StatusFF <br /> Type Business Role Storage Type <br /> Tire Count(Whole/PT <br /> ! (Fill one only) all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 <br /> Q Active Passenger ® Generator Q Outdoor <br /> O Q Closed Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> - Q Inactive Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Co: �[ <br /> Business Type (Fill all that ap` " <br /> Q New Tire Dealer 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 1HAULING 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 m / m / 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 days (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 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 In Compliance No Y•iolations <br /> Q Q Other: § <br /> , . <br /> Comments Q- j✓'�f `C rf((Irt fGLc ; 1jG v) ! (t f b r' 0vi ieL; Gv� no f '� : � '� J�)I <br /> l <br /> Jr C� ir.. �1t fLl Cin 4 <br /> 'f Unr r tlU t_.0 r <br /> Inspection Form Included: QI r , r <br /> Comments Included: } .`._ I - <br /> Business Rep's Signature Phone Number In$pector ys Stgnatur " Phone Num <br /> -- _ - <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �, V (. 7L A M P L E 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> I <br />