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ns ection Report Number <br /> Waste Tire Suzy & Inspection Report p _ p _.._ <br /> ' M State of California f't <br /> CIWMB 181(teManag) Survey Form - Page 1 s 1; ; r$ t_ <br /> California Integrated Waste Management Board <br /> Part A- Survey <br /> BLUE OR BLACK INK PEN <br /> e,rr• j„r y ti ° ba t a2r 2 r y � c �. ta-� + ^. <br /> BlJ rIYlf;$ �', tk s T ✓ti,r 4„ Inspectlgrl �l ki <br /> TPID- „ rrT Inspection Type (Fill one) { <br /> Site Suffix: f f,' `r_I_,_1,..�J�� �d <br /> / t ( Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ., <br /> i r t <br /> Physical Address <br /> Street D/ , / [E-,E/1 r. <br /> 'r ; <br /> C .-� Inspection Date <br /> I_ _ f - �* -1 Time In Time Out <br /> Cray '_ Mete ZIP Co�c, _-- --- EE-1 <br /> Business Rep Title p v 0 AM Q AM <br /> _( 0.PM ._,.__ _ O PM <br /> Operational Status , <br /> w,"" Business Role r,,S orage,'Type, <br /> (Fill one only) 1�'l , 5 1. fy)' (Fill all that apply) (Fill all that apply}. <br /> Active Q,Passenger@ Generator Outdoor . <br /> Latitude <br /> D Q Closed Q altered <br /> GPSQ Hauler Q Indoor <br /> EEL-1— <br /> _.-, 0 Q Inactive ('Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Busipess'Tjfpd (Flit all tha,r ' <br /> Q New Tire Dealer Q Auto Repair Q 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 HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> o Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> o Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> o o PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q o 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q o 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> a o - -- -- - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q o 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q o 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> o o 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators a In Compliance- No Violations <br /> a a Other: § _ <br /> Comments '1 <br /> ,f I <br /> In$pection Form Included: <br /> Comments Included: _ ». _ __: �..a _ .��,.... <br /> a w_. <br /> Business Reps Signa#urs Phone Number 1 spec cir s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0incorrect i , , �_ � 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />