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Waste Tire Su'sby & Inspection Report inspection Report Number <br /> W9 : - <br /> .gym m <br /> State Survey Form - Page 1 - 3 L <br /> CIWMB 181(New 04/04) I <br /> California Integrated Waste Management Board <br /> Part A SurveyBLUE OR BLACK INK PEN <br /> '�-`- rr ar+..M, �r ,kr r '!t"v•f~h1mk;r Nkk'�`(,,ak ifik„a?' A ,� „�"«.�rM,�e?"7a�” a w' G,y rr r <br /> B)ui �� � v4�: <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ! %� ( ELJ 0 Routine 0 Re-inspection 0 Referral 0 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 Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date j J f' / / EEI <br /> Cih State ZIP Code Time In Time Out <br /> Business Rep Title QAM _ Q AM <br /> J , ' QPM ' [T QPM <br /> • <br /> V' r, --- arra <br /> Operational Status a� � n�r��fi"��� Business Role � <br /> ,r <br /> 7T <br /> 5 (Fill one only) ff��I ) ��" (Fill all that apply) , fi i <br /> 1 flu amE/yr, r trrEikf r ,' frt <br /> S Active ���"�4d Q Generator gra � rf <br /> 0 <br /> Closed <br /> GPS Latitude <br /> Hauler <br /> 0 <br /> inactive <br /> Longitude 0 Planned ' 0 End Use <br /> 1 <br /> t,..r ,. 1 a �.Wg. <br /> ,,. t..!7 <br /> r a .. t�;..; <br /> .r,..,.. �, <br /> ::. (r"«k'„: ,�..�77!! <br /> a ..y t <br /> � i �: .. rm >,ta .. ✓� �, � ;r ..... .,... ,,, <br /> i �..�. r�. ct�_2..gk..;_d.,�J,e�, '"�^.,M._.ra. <br /> 0 New Tire Dealer 0 Auto Repair 0 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 /> Q 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 Notice Of Violation 0 Extension <br /> 0 0 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 <br /> 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 /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> l 0 0 Other: § <br /> Comments / \ <br /> '� ,111 l .sr 1,A'" ( I Ne"I i n -'-1 <br /> j , <br /> dd <br /> l <br /> I <br /> F <br /> ti <br /> Ins econ Form Included: Oi <br /> Comments Included: 0 ; <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: ; "' 62081_� f <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />