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Inspection Report Number <br /> Waste Tire Su&y & Inspection Repori ► ■ <br /> State of California iJ� !/� i. <br /> ClWMB 181( ew 0410 <br /> California Integrated Waste Management Board Survey Form - Page 1 1 14 -, 10 Aj S 3 2 2 <br /> Part A- Survev BLUE OR BLACK INK PEN <br /> J�Ti <br /> IteTPID- - _, Inspection Type (Fill one) <br /> Site Suffix: �� +J <br /> _ ® Routine 0 Re inspection 0 Referral 0 Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name k <br /> Inspected B <br /> p y Inspector <br /> Physical AddressEd <br /> EI � I j r tA ry, <br /> Street _ <br /> Inspection Date <br /> Ci— C State ZIP Code { Time In Time Out <br /> Business Rep Title a AM ®AM <br /> ! 7 C f <br /> DOEI� <br /> O PM 7 L!__.._ O PM <br /> Operational Status Tire Type Business Role Storage , <br /> a <br /> (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all thatt p, I <br /> (a Active 0 Passenger 0 Generator 00 f w <br /> - — r~�,+ <br /> Latitude FJ I I 1G 0 Closed 0 Altered tis <br /> GPS 0 Hauler 0 Indoor'" � <br /> _lC 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTS 0 End-Use 0 Container <br /> "7� j <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 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VI 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 <br /> 00 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 <br /> �G,t(✓�� lfl �'f( (.' _ f "\i ( tt t E11. l)l'., r' +slit kli,�'- <br /> -( , 1 ( 1/( <br /> i ( '• " ✓- r' F 1Ct� t�_ Vii( -_C; L,., G1.Fr'7 '-�.. }��� ,i j{, ri .. <br /> J <br /> - - - �d�_tl (iJ. ,1�/ //(. ,fr'7.,s• _ .'cid i /, � c�,� "�i <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:* incorrect: X �, \/ ,., = ; ; i L i <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />