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Waste Tire S ;y & Inspection Reports Inspection Report Number <br /> `oralifornia <br /> 'u CIWtedWa(Waste <br /> eManag) Survey Form - Page 1 1 8 - 1 0 13560 <br /> California Integrated Waste Management Board - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> ar ction Details <br /> TPID- Inspection l� Ed �l� Inspection Type (Fill one) <br /> L/ <br /> Site Suffix: Iv ! V Q;Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local if Referral,choose referral type(Fill one) <br /> Identifier: c� ��t { ��fi44N, �'- 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address / (,+ t,l , <br /> Street <br /> l Inspection Date <br /> City y State Z/P Cod(.: Time In Time Out <br /> Business Rep Title II nn O AM 0 AM <br /> !I W � m0PM m � m 0PM <br /> Operational Statusire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �� ;\ (Fill one only) ,Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> v t Active 0 Passenger Q Generator 0 Outdoor <br /> FF1 O 0 Closed 0 Altered <br /> i IGp$ Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned OTR 0 End-Use 0 Container <br /> New Tire Dealer a Auto Repair 0 Trucking Fleet 0 Government 0 Relreader 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 A HAULING AND MANIFEST REQUIREMENTS <br /> — 0 Notice Of Violation 0 Extension <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 m / m / m <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 /> 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/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 0 In Compliance - No Violations <br /> 0 0 Other: § �J/ J <br /> Comments �l IyJsil{ , )t 1 `{LL l G 1`f / �F2r �1 <br /> 1 i tC cJ L1/1 ' f (���' �i/� D <br /> (t��C;� 1�V� ✓ D L /� f I('� <br /> 04AIPcJ rr vtl kl rf '�l� l 1�T <br /> / <br /> (nspecftori'Form Inc(— -0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X �, ;;, A 1 P I L I El 11 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />