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■ <br /> 'Inspection Report NumberFire S Y & Inspection Re O Waste <br /> - <br /> E 7T-. <br /> iCiLi State of California Survey Form - Page 1 ,, l 3 - 1 5/j/�j <br /> i 4 <br /> CIWMB 181 New 04/04) <br /> California Integrated Waste Management Board - <br /> 8 10 <br /> Part A Survey BLUE OR BLACK INK PEN <br /> �TPID- I � Inspection Type (Fill one) <br /> Site Suffix: -�. %' <br /> _j __ _�__I ,_ _ Routine Re-ins ection Referral0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected B <br /> F p y Inspector <br /> Physical AddressLL <br /> Street <br /> Inspection Date ! _ <br /> — In <br /> City y ---__ -- State �Code Time Time Out <br /> � [:0 <br /> Business Rep Title O AM l O AM <br /> _ � �__._ 0 P � 0 P <br /> 1:10 r <br /> -M Operational Status �rx Business Role <br /> !' (Fill one only) r �gli� )Ihatep ' (Fill all that apply) <br /> ! 0 Active �� t Q Generator <br /> O 0 Closed <br /> GPSLatitude 0 Hauler Inactive <br /> H <br /> r <br /> o <br /> Longitude <br /> , <br /> Planned <br /> a <br /> 'r:r � <br /> rcr +�, � .,k, »„„M ,:., �,~.a: i l„�,:::wu ,"t r,.:„ � k a r...y �" �,�",7�",� �k', a,.,/„e w :,Ar. "' rr ✓: � r�.,.,� "t � }+. 4 ti�.., h "i a!e..Y.d� l ,.,. <br /> 0 New Tire Dealer 0 Auto Repair Trucking Fleet 0 Government 0 Retreader 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 i ENFORCEMENTSTATUS - <br /> _! <br /> V A 'HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 pate m <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18,459.2.1 -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-Manjfest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifes,System Requirements for Waste Tire End-Use Facilities _ <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> y�;a`^� k '�•> ?ata ASL Ma '"ur' r� ��f "^ ^ ,� �4 4 A'' a!" +� lro� ) �Y ,",r'a,��"'" '� haw�r" � <br /> �,✓,°�yr�L�rc;n ", �,�.Sr�y�l�ji181U'I'�,���' 1� 4;=�C1o1T�NWIYIW ;r4, � ,.i �=P�ld�'le.___,yz ��1�°�,��f�(', <br /> - ` 62081 <br /> INSTRUCTIONS ON K BAC ^� Correct:* Incorrect: X Ax I M P; �, 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © S <br />