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Waste Tirey 8c Inspection Rep Inspection Report Number <br /> y® State California Survey Form - Page 1 - 7 <br /> - 1 CIWMB 1S1(New 04/04) ! <br /> California Integrated Waste Management Board ._..__�.. -_-_. _.... _1. <br /> Part A Surve BLUE OR BLACK INK PEN <br /> ��tiix �i sa a yspsm ..� a'� f"rk`r�i. ;"s^"'�"" s Msu di+ � f as;..''`. r r"�, ,f � r+ ✓a r" �:pt";�,s sr M <br /> ttk( ua <br /> Inspection Type (Fill one) <br /> Site Suffix: Hi <br /> TPID- r -A-_ <br /> l..__- '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 / <br /> Inspected By Inspector <br /> __[T1 ,1 � <br /> Physical Address i — <br /> ,- <br /> -- <br /> Stree,t <br /> ` _ f Inspection Date <br /> �.. r�is - .-^� (• �-,'. , .• �.,..:: ,.-.. <br /> J <br /> City State ZIP Code Time In _ Time Out <br /> Business Rep Title 1 Q AM OAM <br /> 0PM m � m I 1 0 P <br /> Operational Status,^s Business Role „ u+ <br /> r l (Fill one only) )tP a (Fill all that apply) <br /> t ; Q ActiveQ Generator <br /> O QClosed <br /> GPS Latitude Q Hauler <br /> O Q inactive <br /> Longitude — Q Planned �;� tiurrzf'i Q End Use <br /> "7u, ,,.,N �, >a: <br /> „..:, �.. d rr,!: <br /> - `, A <br /> tI`a..., �, r... 7" r.:.. �' ,✓". w rx ,..: r .�r.h�... w .PG~".. s^ t:..r� .,s a„j.,s,,.s w+, ✓.,,.. ,w .r rre ,,..'k. a�.... <br /> ^.�. .,.._:��"✓�_.ar--:y., .. <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 /> VA HAULING AND MANIFEST REQUIREMENTS- - -- Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> �i <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 <br /> Q Q § OOO 9 m EEI m <br /> 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 <br /> Q In Compliance - No Violations <br /> Q Q Other: <br /> Comments <br /> 1 <br /> 1r1� ^w s 'i um rs sa ?�: <br /> '� <br /> �� n ra �a ."✓v <br /> ' Comments ri udecP Q s � , t ” <br /> flus n� p S x t° if 'i Phane Number Inspector s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: ; �/ x. _ _�n 62081 <br /> rite r �_,l s <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />