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Waste Tire Suft & Inspection Reportftspection Report Number <br /> E3�3..c State of California _ <br /> Wrnia CWMB grated Waste <br /> eManage) Survey Form - Page 1 11 a 1 3 5 Z 7 <br /> California Integrated Waste Management Board - ---�-- --- --- -----� <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> y <br /> till '� <br /> TPID- � - Inspection Type (Fill one) <br /> Site <br /> Site Suffix: 1111 I p �� � �• / Q,Routine Q Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ( d` ri1: O CHP O CIWMB Q Complaint Q Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address y -� <br /> Street <br /> Inspection Date I / f-.7 ..'! <br /> City State ZIP Code Time In <br /> E <br /> Time out <br /> Business Rep Title O AM O AM <br /> �[T--] ' EO PM LLI : EEI O PM <br /> t/ �1 ! TJi <br /> Operational Status Business Role <br /> (Fill one only) (Fill all that apply) ; <br /> (D,Active m r Q)Generator C 't tlttiopf <br /> 0 O Closed <br /> GPS Latitude LHI0 <br /> Q HaulerInactive �r #' �"�Nµ°�t� <br /> Longitude 0 Planned �t � (,����"t End Usep +„ qt )m�;� <br /> 0 New Tire Dealer Q Auto Repair O Trucking.Fleet O Government O Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler O Agriculture O 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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB it <br /> m m m <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 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire GeneratorsT Y <br /> In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> a <br /> b � — <br /> a rrou+ <br /> Ode' <br /> - /� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E"XI/IP a <br /> - _ - - ■ <br /> ■ White Copy:CIWMB Yellow Copy:Operator ink Copy:LEA <br />