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Waste Tire SAI-Y & Inspection Repo4o, 'Inspection Report Number <br /> State of California r <br /> }A� <br /> Californ�iailnt gra B 181 WaseeManagementBoard Survey Form - Page 1 Vj 10 06 � 5 <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Inspection Details <br /> } TPID- ' D I I Inspection Type (Fill one) <br /> Site Suffix: t/!nr �i ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: Tor,( t Y QYl� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> 0Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> Physical Address �. { <br /> ci <br /> Street <br /> i <br /> Inspection Date <br /> ait <br /> r ✓ I _- C �. CA / ..: CJI <br /> City �— State ZdP Code Time In_ Time Out <br /> Business Rep �� Title 0 <br /> T3 (ill PM � –� . Q AM <br /> �i -� r 'I rkI >! �(,H-�f A,)0�Y ,. � I;)t„���� �'1(��I�.t _ � QPM <br /> �� <br /> Operational Statusa , ��, �,,� Business <br /> i✓ (Fill one only) (Fill Gt (Fill all that apply) MI� t� iI� <br /> Active � � � � Generator(' <br /> ,„ <br /> GPS Latitude . O OClosed <br /> Hauler <br /> 0 0 Inactive <br /> Longitude £ ra,+r,l s,t,it� r�+ � ynry; err` <br /> – � i� 0 End Use <br /> 0 Planned <br /> ���`���� �� ���� "�t as r(��r i��E,t ter✓� <br /> USI17�S�� <br /> -_ <br /> w4E,�.0 <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A i HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR£18459 -Responsible Entities Complying with Manifesting Requirements Date EE / F11 / Ill <br /> 0 0 14 C(fR 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Wy'ste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments < r <br /> - (( �1 r_1 ` l l)r`J I6'J �t-f L�1G S� Nluf('c <br /> i <br /> 1 t `� V i A(� 1�{ vii!`�7 f' `�l f�'`� E'7t"t l:t I�'l F ,J t� �P`��-C,��;r� -�'''t, r ��1�./lI_s�: -�. �fP✓ ' <br /> t l l r�vLctJC � _ t t�i.�s ; ']�. ;rr�,r < 1tLV rrr ,fes by 14r� <br /> k,o t u(k ij rl oo l y0(+ el In �i�1�tlAff) `,1/-/477 17, <br /> Inspection Form Included: 0 ” <br /> Comments included: 0 _ <br /> Business Rep's Signature Phone Number Inspectors Signature 'hone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X <br /> ■ _ ._. ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 4,; <br /> y <br />