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■ Waste The Su y & Inspection Repor Inspection Report Number <br /> _: ■ <br /> State of California `. �/�i j <br /> 04/04) <br /> California:Ine grat df81 WaseeManagementBoard Survey Form - Page 1 lj l 315 5 <br /> Part A- Sufvey BLUE OR BLACK INK PEN <br /> TPID- (, -, ( Inspection Type (Fill one) <br /> Site Suffix: `j !�' c� �: t I <br /> (j) Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: b( ,4.«1 �, �� O CHP 0 CIWMB 0 Complaint O Educational Visit O Other <br /> Business or Facility Name <br /> -� <br /> - - - - <br /> t_.. <br /> ,. ., Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date <br /> City State' L(P Code Time In Time Out <br /> Business Rep TitleAM �l Q AM <br /> C- O PM <br /> v. 0Operational Status Business Role <br /> 1 (Fill one only) } l atr ) z (Fill all that apply) <br /> % ca Actives , Q Generators <br /> * * <br /> PSLatitude O Closed <br /> G 0 <br /> Hauler <br /> O <br /> Q Inactive <br /> Longitude - Q Plar nedra4 O End-Use k <br /> - - L <br /> O New Tire Dealer Q Auto Repair O Trucking Fleet Q Go% ment Q Retreader O Dismantler0 Tire Derived Fuel <br /> `s Used Tire Dealer O Auto Body O Car Dealer 0 P4 lection O Crumb Rubber <br /> Q Service Station O Hauler O Agriculture Shredder O Other . <br /> Part B - Inspection of Waste Tire Dealer, Generat6r, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 'HAULING AND MANIFEST REQUIREMENT <br /> Q ' 0PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation O Extension <br /> i <br /> O O PRC§42953-Contracts with Registered Waste itire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities ComplVng with Manifesting Requirements Date <br /> 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or E)(T) <br /> O Q 14 CCR§18459.3-Retention of Manifest Forrhs and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> , <br /> Other:. §, <br /> Comments �' i <br /> I <br /> � l 6`''.� t:,l �)(. 1 s`jol <br /> LJ�, a <br /> , <br /> n # 'rv ,::rNyyr CM"ar;rt rw? r,u r;w" ✓y:: r#r § r rr 4 �� 1:'�^ r ,.y.,.. 1 -_ w "' �`,n„tr ^.an ','S ,"•*u.*m" ", wSv 'fit*;MF:rk g,"wy'sr "* ✓ r• <br /> , rr'ry, arca„� <br /> w� k <br /> r+~..;. �x,3, ATM <br /> Inspeetfan Fartri 'Incl�ided' (.„: ^, a'"f� � ,t , •, � � � z � ���r �. � <br /> Comments Included <br /> ��••w.": <br /> Business Reps StgnaCure Phone Nur►F�Y�" �*trpa , ” ."�.r",^,�, e U er <br /> _- <br /> ■ INSTRUCTIONS ON BACK Correct <br /> ncorrect: X y, F , ,�", IF: � j C a 3� 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />