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ns ection Report Number <br /> WHOM <br /> Waste Tire Su & Inspection Reportp pState of CaliforniaCIWMB 181 New 04104) ' S I <br /> California Integrated Waste Management Board Survey Form - Page 1 `` 7 ` l 1 <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> TPID- Al I„ Inspection Type (Fill one) } <br /> Site Suffix: I 1( .i ( <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local <br /> -- ' -- <br /> � + If Referral,choose referral type(Fill one) <br /> Identifier: <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name t' <br /> t Inspected By Inspector <br /> _..d _ <br /> Physical Address <br /> —d � <br /> F <br /> r <br /> Street / / . <br /> Inspection Date <br /> I 564� <br /> City —� State Z1p Code Time In [_j <br /> Time Out _ <br /> Business Rep Title AM 0 AM <br /> .......10 PM L 0 PMOperational Status Tire Type Business Role 9 <br /> (Fill one only) ! (Fill all that apply)': (Fill all that apply) <br /> 4 Active Q'Passenger Q Generator <br /> Latitude <br /> . ^ � O Q Closed Q Altered <br /> GPS � Q Hauler <br /> 11��.. 990 Q Inactive Q Tfuck <br /> Longitude ! Q Planned Q OTR Q End Use all <br /> Business Type`> (VIII alI that apply) <br /> --- - --- - — J----- -- - _ <br /> Q New Tire Dealer Q,Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler 0-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 <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB m / IE / m <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive 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 /> v",=' In Compliance - No Violations <br /> Q Q Other: § <br /> Comments ( } <br /> t _ <br /> JYr -• � ' (J✓`G +`flirt F ; <br /> t <br /> :. i <br /> "(_.d :( - �( r "T_ ...i.( � .i ,V� V_J I L <br /> �r /X IEa �': �i i 5( � I;�S' .t �.��- Ji. l �,d.. 'i,,'✓ a.. d'�� ly't �� .r! r�Y i< �) 1":�.�`. i <br /> x r <br /> " 7` -''` ,.•a;r,;y ^rr a^a",'wf�y���,r , 2a :nsww.y" " �r� ,ter^: ua1*fl'7"'M"T' u^Ya`„Yf*'a*'lf” ,e7 sr ar"„„aa.,Tudw ;f„t,w»; m«w;t; ,r^**Ft>"�tpa^f;"l.TM,�° ;rren rrvra u,$ax ” f3,7,a:�itsJ.» Wa' • <br /> Inspection Form Included.-. Q <br /> Comments Included: -:'(D <br /> -- -= — — <br /> Business Rep s'Sfignefure Pone Number tnspector,.s Signature Phone Number <br /> T- <br /> _ _ -0 -- <br /> lI� .._._� � 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: A, J� E , _ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />