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Inspection Report Number <br /> Waste Tire Suoy & Inspection Report <br /> � State of California <br /> 81 Califon a¢InteIWMgratd,Was New 04104)Management Board Survey Form - Page 1 I 1 - 10 1 3 L�j //�L 6 <br /> tart A-Survey BLUE OR BLACK INK_ PEN <br /> Inspection Details <br /> TPID- I I ( I - — Inspection Type (Fill one) <br /> Site Suffix: I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local, r 1 / j If Referral,choose referral type(Fill one) <br /> Identifier: R.. `rG4 ( .. Ln /, .�(.i (. - 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name _ i 'i Inspected By Inspector <br /> Physical Address I r I I o <br /> Streetf_ <br /> t ) Inspection Date /,� (dc <br /> I �l�Q Yl C � t to ✓1.'t/', �_� � ,,�,f, , :: � I s✓ <br /> City `� State ZIP Code Time In Time Out <br /> Business Rep j f TJiittller 0 AM 0 AM <br /> /alt.; 1i�yla i�l((I1 t_:1 1" �'�� t / O PM 0 PM <br /> Operational Status ire Type Business Role Storage Typ <br /> Tire Count WholelPT (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that ap <br /> ( Active Passenger Generator 0 Outdoor. <br /> I it' 0 Closed '0 Altered <br /> GPS Latitude I `-_I- I 0 Hauler doo <br /> 0 Inactive 0 Truck <br /> Longitude - I I I I 0 Planned 0 OTR ® End-Use tainer <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AIVU MANIFES"f REQUIRENIEN'I'S - -_ 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 M / M / m <br /> 0 0 14 CCR§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 Waste Tire Generators <br /> In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments ') %.. { <br /> (�tDL( !tfl � �t(. r �. %�".X )��r�tc._�lr �( %" . <br /> I _ � !tet_.'. 1,. <br /> --1- __.�z✓� �;c r Jir c c C�: i e -71 r k- 06 T 7( 1 '7;rF 1, <br /> r , ; tJ <br /> 1j_T 1/I� V1 f'<.� ��Y� 10 11 �%r u`-lf(` ` t`_�CCtt;yi2L L�tly �I/E CJS' `felt 4- I!/ <br /> 1►w�- ��.. . ��_-S1'�,( �'f.-1. 1-k, f ,(/1�_r rt.l� 1 tIby(,� `_ " 1 � AL �Li: II f' f.}LI ! '. l-£ P-j <br /> Inspection Form Included: Cy <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X Ak \/ X1 A M(P I L 1 1� -11-12131 L208' <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />