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; .. Inspection tion Report Number Tire e O -Y & InS ection R
<br /> C8
<br /> IWMB 1State of Cal1form _
<br /> Survey Form Page 1(New 04/04) I j/''�� ''ry._._7 -...8-
<br /> _-.--_
<br /> California Integrated Waste Management Board P, _ - f__ �F 1J
<br /> Part A- Survey BLUE OR BLACK INK PEN 11isil i;TPID- Inspection Type (Fill one)
<br /> Site Suffix:
<br /> O Routine O Re-inspection O Referral O Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: L '_A-\F1 O CHP O CIWMB O Complaint O Educational Visit 0 Other
<br /> Business or Facility Name
<br /> � Inspected By Inspector
<br /> Physical Address ^J
<br /> Street
<br /> Inspection Date
<br /> J7�,
<br /> City State ZIP Code I Time In Time Out
<br /> Business Rep Title 0 AM Q AM
<br /> Fj
<br /> � � OPM C LLI 0 P
<br /> Operational Status Business Role a ✓,
<br /> (Fill one only) (Fill all that apply) '
<br /> Ilk,_E." °,i�l..ae , .:r?Mt , ✓s .,«. ,,a„cs},..r �,'N✓r . O Active Q Generatory
<br /> +'
<br /> 7 b� y+'rora yw , MUNE j�ra} "7
<br /> f O s +t+ uGar ✓ta i' 1 � �d ,tir .
<br /> tl O Closed P
<br /> Latitude _ O Hauler
<br /> O Inactive ! r+ Tr�,fir� rrt"ainl
<br /> „
<br /> r" ��� L fir' trir1� f✓ " y
<br /> Longitude — O Planned isr rye�ts; O End Used ( *
<br /> O tla N G ✓ l��✓ r! eda� I
<br /> la
<br /> ri ,' :Si"9 x-r fwi ,1 5r;,y;,a y��*'yt a yX�p`" ,l, 1":11: s Id?,'!""u ' a q yf,a +4Ct✓t w'/ -"'. `yl�yM1"ry,
<br /> r�,: ✓ ;aY /.a t s y y 'Si ✓uta",,..,,�+a? '/S. ✓t ✓✓ tc.: er ✓d,y9 /r.: ani. ✓a u a �„Sau'�,et +5yac�.. 4++t! t
<br /> _:_.�.,. ru"w�i.a2ta�n.�..,.✓.,,»�, "y .��w.. L`_`�,_� �_�.,:...,yy�.e,.� �trv�_"s_l..a`t'✓."� " win ..t:.y o-�...�'�Sd!�,+�'^ '/.__ �;! i x..y'i.a,_.F'��.y✓��°'t�. t tireSatu ��..Mc,t.u.,..�!�...:3rvct�+ ..!r.L....:
<br /> O New Tire Dealer •),Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel
<br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection 0 Crumb Rubber
<br /> O Service Station O Hauler O Agriculture O Shredder O Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS fl
<br /> V A HAULING AND MANIFEST REQUIREMENTS ) Notice Of Violation 0 Extension
<br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> O O 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 /> 010 114 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 I'I 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 /> O O 14 CCR§18461 Manifest System Requirements for Waste Tire End-Use Facilities i"A �� �� �fa� ��t
<br /> O 014 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators k
<br /> 0 In Compliance - No Violation
<br /> O O Other: §
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<br /> Comments
<br /> V r t
<br /> INSTRUCTIONS ON BACK Correct:* Inect X '46i, �/ A M, �
<br /> corr62081
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<br /> Ate,- ■ " White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® S
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