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J <br /> s'ci' ection Report Number <br /> Waste Tire Y & Inspection Rap1111s, <br /> pState of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 7 - 10 7 3 .3 9 7 ` . <br /> California Integrated Waste Management Board - <br /> Part A- Survey BLUE OR BLACK INK.PEN <br /> v — -- f Inspection Type (Fill.one) <br /> Site Suffix: 0,Routine -Re--inspection <br /> ection 0 Referral. 0 Observation <br /> f'Rep �Qn�hosre ( <br /> - -- - - <br /> ca <br /> ferraf <br /> Identifier: . O CWMB OCom Complaint OEducational VisitOOther- <br /> 0 PCHP I <br /> Business or Facility Name ! Inspected By Inspector <br /> k'aworI "&► lE�., ;:ctCa tr f <br /> Physical Addressj ' E' t t i' t. t <br /> Street / ^ } Inspection Date 2 <br /> [ <br /> State ZIP Code . Time In <br /> City Time Out <br /> Business Rep Title AM m Q AM <br /> � F0.PM .� W ,0 PM <br /> I I Operational Status' tr " yp'e Business Role <br /> 1 - ' OUrI 110'le� <br /> (Fill one only) U01 that apply) (Fill all that apply)' <br /> - _ _ <br /> <' —-- ( Active assenger Generator <br /> O 0.Closed Altered <br /> GPS, Latitude 0 Hauler <br /> 0Inactive Truck <br /> O <br /> Longitude - O.Planned End-Use <br /> Business Type (Fill all that apply),,: <br /> O New Tire Dealer O Auto Repair 0 Trucking Fleet O.Government: �O�Retread& 0 Dismantler 0 Tire Derived Fuel' : <br /> O Used Tire Dealer 0 Auto Body O Car Dealer, 0 Collection. '0 Crumb Rubber <br /> O Service Station '0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility J ENFORCEMENT STATUS <br /> - -- -- <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - - <br /> -- 0 Notice Of Violation O Extension <br /> O O 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 -Tire Program ID Number from CIWMB <br /> O O <br /> 14 CCR§18459.2,1'-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3.years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ® 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 <br /> O - --- <br /> In Compliance No Violations <br /> O 1 O Other: § <br /> Comments ?> <br /> e/L4rt.l,k cl I,t}G+�t(:., f11/1 c t :rS, : ( Ke ,) <br /> -F - /0- fog ( <br /> pf-civiowr 0/1& <br /> 7 :,port /b /3r/� hof i o £ ti ��I <br /> 7�r fes.t�1 C[ ✓ C � 'r? _ �t ��t �'P(��)��� �f,��_ - <br /> Inspection Form Included: 0 x ��~``�6�� / <br /> Comments Includad: �' f pf `f I l '�-,�� C)_C wnt 56c,'� ' <br /> J Business Rep's 5inature Phone Number Inspector s Signa re Phone Numle <br /> -- _ - - <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ' I E� A ��T i1,11213162081 <br /> White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA <br />