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Waste Tire SL_ .:y & Inspection Report Inspection Report Number <br /> `j� '• Stale of California <br /> CIWMB 161(New 04104) Survey Form - Page 1 0 t t Q <br /> California Integrated Waste Management Board J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- r/ ci Inspection Type (Fill one) <br /> Site Suffix: l`1 ip } 1p t ) ® Routine Q Re-inspection 0 Referral Q Observation <br /> Local ,r, If Referral,choose referral type(Fill one) <br /> Identifier: 0 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 1Ll �1. <br /> ( 1 <br /> Ph sic I Address <br /> Z C� l7 D <br /> 2 J Inspection Date J C Z �" <br /> Time In Time Out <br /> Business Rep Title `LI LlO AM O AM <br /> �-Q t tti wt1 1 Z S PM ® PM <br /> Operational Status Tire Type Business Role Storage Type JI <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> Tire Count (Whole/PTE) f l <br /> 0 Active 0 Passenger Generator Q Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ® Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use Q 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 0 Agriculture 0 Shredder Other l� ��GL✓1��( ��� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VI k I HAULING AND MANIFEST REQUIREMENTS <.; , <br /> 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 Ao <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 DCT) <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 I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities __._ j <br /> 0 ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> 0 Other: -- <br /> - l _ <br /> Comments%VAAL <br /> Lli�l.t�6 , <br /> Inspection Form Included: 0 � � �3Y I- I _ ` �j .� T —��?o <br /> Comments Included: 0 _pt,(,� �' O4•�—L L <br /> Business Rep's Sig a Phone Number I spector's Signature Phone Number <br /> INSTRUCTIONS ON BACK 'Correct. Incorrect.Xl /jjEjXjAjMjP1L1E1 111213 62081 <br /> L - <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />