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Waste Tire S & .Inspection Repor !spection Report Number <br /> _ State of California - I <br /> ester CIWMB 181( e ) I i 1 0 3 3 9 7 1 <br /> California Integrated WasttManagSurvey Form - Pagel 1 <br /> Waste Management Board _�..... ......_ .. __..._ ..__._ -. <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> TPID- Inspection- Lo-L <br /> Inspection Type (Fill one) <br /> ?SiteSuffix: ! 4- Z_ 0 Routine 0 Re inspection 0 Referral Q Observation <br /> 11 <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: `., - � c f1� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street ,�f�Inspection Date © `7� DE4 <br /> City I (% State/ Z!P Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> 1 qi f QPM QPM <br /> Operational Status Business Role Storage Type <br /> (Fill one only) ( till t �tyi), (Fill all that apply) (Fill all that apply) <br /> Trre Count(�lVho(e1P'TE) <br /> Active e ) a Generator 0 Outdoor <br /> GPS , T10 ClosedIt (� 1"f r 1 <br /> Latitude ai�w� 0 Hauler 0 Indoor <br /> r-----J-� ��---�----�---f---� 0 Inactive [ ""1"�Gnl>w G ,i <br /> Longitude - 0 Planned D OTR 0 End-Use 0 Container <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 Q Agriculture 0 Shredder 0 Other I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 C ! f r <br /> 57 <br /> ""l :r^E.- L:"�C%!`.. . ./-. �r, i-< / y-�+[,/� I,..Jc+. l 1_� 1 �- `�( r"- r✓ J �`%t �•�!6 �i.- _/ l � t- <br /> I� <br /> - J f;.---'4 t1(• �- ��r.,7...7 .f=,,'G...� � t" - ( :-t t..H Lam-. ESC. ....H.'�' - <br /> /+ <br /> Inspection Form Included: 0 <br /> Comments Included` 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:10 Incorrect: X A 4 d_,I� _ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />