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F <br /> ■ <br /> Waste Tire Suew 04/04) <br /> y & Inspection Rel tInspection Report Number e LnG57F State of CaliformaCIWMB 181 ..,_ <br /> California Integrated WastJe Management Board Survey Form - Page 1 1 0 - 10 -1 4 7 v. 0. <br /> gtrt <br /> Part A Survey tll Inspection Details BLUE OR BLACK INK PEN <br />} TPID- Inspection Type (Fill one) <br /> Site Suffix: LLJ L—L-1— ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �^ If Referral,choose referral type(Fill one) <br /> Identifier: Q`-}t 4 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name y" Inspected By Inspector <br /> A <br /> Physical <br /> _. .ddr_ess.�__� s �'-� _ � ( C� ! 1 � Q:,y Yom.�I <br /> '� �' �I <br /> ,... <br /> Street C� Inspection Date <br /> Ji <br /> City State Zip Code Time In Time Out <br /> Business Rep� . Title Eil : CE O PAM 0 AM <br /> M 0 PM <br /> �f(Jr.. ,� I yra <br /> -i ----I Operational Status Tire' , � f Business Role Storage Type <br /> (Fill one only) (Fill ali'(tr' a (Fill all that apply) (Fill all that apply) <br /> The Count(Whole/PTE) <br /> (iij Active Q PQ Generator Q Outdoor <br /> � t <br /> Q� Q Closed Q <br /> PS ?c ") <br /> Latitude e �,"s <br /> Q Hauler Q Indoor <br /> o Q Inactive <br /> LongitudeQ- Planned Q OTR Q End-Use Q Container <br /> l.. <br /> Business Type (Fill all that apply) ' <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 Q Notice Of Violation Q Extension <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 /> O 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 /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - _- <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § _. - ---.--- -- - - - ------ - _:I <br /> Comments �� ` LA S <br /> f 1 <br /> Inspection Form Included: Q <br /> Comments included: Q <br /> Business Rep's Signature Phone Number ,Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® incorrect: X �� E , A , , T� El i L .= a 62081 <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />