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.4 & Ins ection Re p p <br /> �� WasState of ,tea Tire � y _ Inspection Report N �mbe� I <br /> CgraMB ted , tJeManage ,survey Form - Page-1 f 3 - 1 0 2 5 0 0 $ <br /> California I(�tegrated Waste Management Board _ <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> ,44 11. NONE <br /> t TP1D- m Inspection Type (Fill one) <br /> Site Suffix: EE Routine Re-inspection� Q P Q Referral Q Observation <br /> Local ' <br /> If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> Physical Address <br /> -- <br /> __J <br /> Street <br /> Inspection Date <br /> Citv - State ZIP Code Time In _ Time Out <br /> Business Rep Title l O AM Q AM <br /> QPM EI 0 P <br /> %11, Operational Status ��y �t; " Business Role �� ' , <br /> (Fill one only) t" tO ' (Fill all that apply) <br /> - rr Q Active � ",;ase � Q Generator <br /> � w� �f�� <br /> Q Closed .Trr f��)rtrf <br /> FT-1-1fi a i" Q Hauler <br /> GPS Latitude r;, M4 <br /> O Q Inactivear '"/4Wr( ' d •yy iN <br /> „fir i��al������ <br /> Longitude — u _T Q lr,,"t t„ Q End Use t <br /> Planned t GHJ r. <br /> rc:._:,.� ,nv.. : .�. ..,,. �:,_ .. .._v:,1. sS. ., , ��>�.a_w.u�„� rd..�i�,rtI �u 1,r.aa1 '�+„�.k:�w�,�Mr�"",n•"�«6�r""�,.�c".ww>',,,J:.<.�Yw r.rDS,�"r�✓ <br /> 1 .. .... <br /> ire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader .$,Q�1' aD�i,ksr�mrzan�""tlwwer �Qe,v��rs�vwf,finTire <br /> .u�Derived <br /> erived Fuel <br /> Iu.t��eY„lQN ewT <br /> Q <br /> r <br /> , <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> p � <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ; A; HAULING AND MANIFEST'REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Notice Of Violation ;Q�xtension <br /> Q ® PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> IEQ � ' 14 CCR§18459.1 (a)(b) (c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years — - - ---" <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers I Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> O O Other; § Q p lations <br /> Comments - <br /> i 1 <br /> f V i <br /> Inspection Form Included: Qi <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number. Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X 1 2 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />