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Waste Tire Su#* & Inspection Repor 0, 11spection Report Number <br /> State of California ■ <br /> M rnia CIWMB 181(New <br /> Manage) Survey Form - Page 1 ! 0 3 6 4 <br /> California Integrated Waste Management Board -...... .... <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile /" tf .+.. . . <br /> Ste Suffix: / Inspection Type (Fill one) <br /> I 17 <br /> 0 Routine il <br /> _ e-inspection 0 ReferralQ Observation <br /> Local i.. If Referral,choose referral type(Fill one) <br /> Identifier: t-- 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> .__..e <br /> Physical Address <br /> Lz <br /> Street <br /> �l Inspection Date <br /> V <br /> Cif State ZIP Code <br /> e Time In Time Out <br /> , <br /> Business Rep Title �} Q AM [1];� <br /> ®AM <br /> 0 PM 0 PM <br /> Operational Status Business Role M <br /> (Fill one only) (Fill all that apply) n,l '�t�� J tk <br /> ® Active ,� f (4 Generator <br /> Latitude ` D Closed Vii°t sia� �pt,tw <br /> GPS * ref yxf a t Q Hauler <br /> Inactivexa'� <br /> D � hNli <br /> ' <br /> Longitude - 0 Planned 0 End Use � � <br /> ''dd l dry ry "i rE4 i"T�r �7mtl i p/ ,„ d <br /> All <br /> ,:. ..,.,. �"q mX�,g,r+ v r, "ktitTM4p '",r /^Y k,.., g✓ w"i N ""u w w ""� t8 �^F Fes' *7 '*`" <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 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 ENFORCEMENT STATUS <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 Date m / m / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -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-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> -. -. . :. _ ----._. . <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 4- <br /> } In Compliance - No Violations <br /> 0 0 Other: <br /> Comments i A <br /> Y i j[ �f. ,: �'�"/ i`//"`G�� �t~'► f -~'`"(�� �./ ��' % � i r_.a 7'� .;�� /� �s..ct.'�r r70 <br /> Jy <br /> �6 }�> e7-_61? ! r T L <br /> IN3'InES� <br /> INSTRUCTIONS ON BACK Correct: Incorrect: (J 's/' , ", p 1 2 3 62081 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />