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A&. y.JAl <br /> . <br /> eT" <br /> r <br /> ( <br /> L.-= Waste Tire SL_ y & Inspection Repor Inspection Report Number <br /> f rni,l CIWMB 8a teManage Survey Form - Page 1 t -California 1 0 1 3 4 1 9 <br /> California Integrated Waste Management Board <br /> 'artA- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- ' f � f-�I � I � I � � I - I � I f Inspection Type (Fill one) <br /> Site Suffix: I (� 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: r! I ����[A ty'l Gu ll ' Y 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name " �L/ <br /> Imo-. Inspected By Inspector <br /> bhysical Address <br /> Street <br /> _ Inspection Date r <br /> City !State ZIP Code Time In Time Out <br /> Business Rep Title _ O AM O AM <br /> 1\f j j /1 O PM I �I / I, !J 0PM <br /> Operational Status ire Type Business Role orage Type <br /> Tire Count(Whole/PTE - r (Fill one only) (Fill all that ap (Fill all that apply) ill all tjatappl,_ _ ® Active 0 Passeng. ®Generator Outt��� 0 Closed 0 AlteredLatitude Hauler do0 Inactive 0 TrucLongitude - 0 Planned Q OTR (& End-Use <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 /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler (a Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 1 A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments jj <br /> "rtlt_ �`Y�` t <br /> ,,, � ,, , , ,, —� , its _ )�( t wl����� t�Ua`;tY tcr�- arc{ a�-U�e sr� r,ualfs �•t <br /> J <br /> p u perr 4 4 Ovid v /(o r t �i� /1� on ck C1 C_ -fro d t S� c� � r�r `� n-pvI►f l <br /> -' Fnllec4 . 1"-ne r +. CO i.( f1 ory � f • ( .Gde✓lt IjQ < E <br /> fpecliI64i gorm MEIu ed: <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Numbe <br /> X � EJXJ ��I I I —I I L I 1 _ 62081 — <br /> INSTRUCTIONS ON BACK . Correct: Incorrect: � � �( A ,.! F � � 1 2 3 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />