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® Waste Tire Su�ey & Inspection Repor Inspection Report Number <br /> 2m.v7:i- <br /> State of California <br /> --- ---._.._.__---A-_---- _..._- --__. .- ■ <br /> Salim.riCIWMB 18ast(New Manage) Survey Form - Page 1 � _9_- � 0 1 3 � � 4 <br /> California Integrated Waste Management Board � <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> OILrFmErni091"flMt ,^ Fr,r la✓ 1 :!^ +; y nwF rwArr„rryr <br /> ” °�.y y ���,� <br /> TPID- s _ Inspection Type (Fill one) <br /> Site Suffix: I 1 ``✓ ® Routine Q Re-inspection 0 Referral Q Observation <br /> Local <br /> Identifier: ` If Referral,choose referral type(Fill one) <br /> + }} <br /> �� G` �� '(,CLvin�t Q CHP Q CIWMB O Complaint O Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> Physical L <br /> Address 17 F - ' <br /> ( ems Y'i.- -(,t <br /> L. <br /> strser <br /> l_�J Jn Inspection Date <br /> State zip Code <br /> l sr I Time In Time Out <br /> Business Rep TitleQ AM <br /> : LP0PM QPM <br /> r� Operational Status , 1" Business Role r t <br /> (Fill one only) 111 �� (Fill all that apply) " <br /> 0 Active f'�� t ® Generator <br /> LLLLil 0O ClosedY Mir*u 4,^lrriw. P,t +ad� <br /> Latitude te G � i;i <br /> GPS � <br /> Hauler <br /> D O inactive <br /> t�r, <br /> Longitude — <br /> 9 Q Planned End-Use <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet O Government Q Retreader O Dismantler O Tire Derived Fuel <br /> @ Used Tire Dealer O Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> 0 Service Station Q Hauler O Agriculture Q Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - - <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> -- <br /> 0 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q (S 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date mm / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV orEXT) <br /> O Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years -- — - - --- <br /> Q 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators tp <br /> Q Other: § Q In Compliance a^•v I rbh <br /> Comments / f <br /> �t (► (. (r f k.' (�' fy._i --all -a 1, 4 <br /> ...-j �I,^ t r ((ice` i((/ <br /> 1. J j "',�.t.��( .J�1 <br /> 1`( f ";a(t` i IY') ttrc_ i-C p�� t it. ��- ( } r t <br /> ID i4 C(. ' {r t i)T <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: 'xY p ' "I 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />