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Waste Tire Suy & Inspection Report._Inspection Report Number ■ <br /> State of CaliforniaCIWMB m jj�� t/1�, �/ryS �/r�j <br /> ew 04/04) <br /> califorrnaIntegrated�Was81 teManagementBoard Survey Furl 1 1 - Page 1 1 9 1 V V V 4 5I V I <br /> Part A Survey BLUE OR BLACK INK PEN <br /> — <br /> ���� � a. a s rG1��s"'�r"�s�_� w, �n a), � a r• .0,�t�,3 q �Y 4 i.� _�. .w.____ ...."_._�...�"x`�."._y____ <br /> Site Suffix: f > -� _ T� `": '� � � / Inspection Type (Fill one) <br /> TPID- C f �- �'�� )) Q Routine Q Re-inspection Q Referral Q Observation <br /> Local _ 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 Inspected By Inspector <br /> LEPhysical Address <br /> Street <br /> Inspection Date <br /> City State ZIP Cade I Time In _ Time Out <br /> Business Rep Title0 AM 11� Q AM 0PM �I � � 0PM <br /> Operational Status Business Role <br /> Tire Count (Whole/PT (Fill one only) (Fill all that apply) 1 <br /> E' <br /> Q Active Q Generator " <br /> f , )Po `iar,,Po''I�a, •� r <br /> O Q Closed <br /> GPS <br /> Latitude � <br /> Q Hauler <br /> � 5I <br /> p Q Inactive <br /> Longitude - Q Planned Q End-Use <br /> Pots <br /> BgSlri�', � r ra dlw.";p""�"�2 ^� �"'" Alr;.f ;. •, y C e t,„;w v,"M rr d4:, .fa„ .,Pow �', Ma Jm. e � k nk,'ti #�a a «"� "` ;A f <br /> �._ ,,�"�_ y�°��_«...L��.y ��si�v_+r��_� "�d„",,��Sw, a,,�ftr � ,�,,s✓fit ^ �r:"fit ��`t.��t'"�„,{��;����,�wl.��,y`�*�'s����reuC�L ��� ���?��������v�n✓��sr�r��f�!/�m�, <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> -.--,-- -_- —_-.- -_--___.---------___ _- --_--__- Q Notice Of Violation Q Extension <br /> I <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 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 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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> ` r <br /> Inspection Form Included: Q, <br /> Comments Included: Q - - - <br /> Business Rep's Signature Phone Number inspector's Signature Phone Number <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X +s Y i A ho, � �L i � 1 I �u <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />