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Waste Tire Sufty & Inspection Reporinspection Report NumberState of ■ <br /> ew 04104) <br /> Cali a In egrfornia <br /> at d Waste Management Board Survey Form - Page 1 �.__6 -_� 1 0_.„I Q 2 <br /> Part ASurv�e rBLUE OR BLACK INK PEN <br /> �Y., <br /> of <br /> r`;' a"", <br /> , .r iJ::,�t _>.s.,sa s "r v u, l ✓ + A , p;;s. n rzv,;{,ws rr~, yr°,°"v, a star", vw �i" , Nrrtt "r "fir �, <br /> �_ �^:e.,u` <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: L..-' I <br /> -� �/ j (D Routine Q Re-inspection Q Referral Q Observation <br /> Local -- f If Referral,choose referral type(Fill one) <br /> Identifier: �y( � {. <br /> 1-.` f r Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ( �; --- — <br /> Inspected By Inspector <br /> Physical Address f / <br /> I� -� t l�l t, art ���`(` • l <br /> Street <br /> Inspection Date <br /> State t ZIP Code l' Time In _ Time Out <br /> Business Rep Title c O AM Q AM <br /> 0 PM O PM <br /> Operational Status Business Role Storage Type <br /> (Fill one only) $�� , � r �" (Fill all that apply) (Fill all that apply) <br /> (��J� <br /> Active � (r 4 Generator Q Outdoor <br /> GPS <br /> Latitude Q Closed <br /> • TTIO Q Hauler Q indoor <br /> _. Q Inactive '�✓�+I�" c���'y � r <br /> ta, t t aJ v AV, Qr �ytit� <br /> Longitude <br /> etude — Planned " "' � )r End-Use <br /> Q New Tire Dealer Q Auto Repair (9 Trucking Fleet Q Government Q Retreader Q Dismantler Q 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 Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 1:0 E[1 Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB I <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 /> 1"n C <br /> Q Q <br /> Other: § <br /> Comments L f n <br /> t'r d �(�r C{,C�.>z)C', i.I: ✓ �r�C�✓t rr'�C.>/: t c 1 _ �Gct r.f u{r: S .. �� ( { (F; <br /> t_ <br /> :D i Li 1(. <br /> er a0 rr ' <br /> id Gs�`,„ <br /> r <br /> INSTRUCTIONS ON BACK Correct: ;Incorrect: ; �/ �,�, ,° ��^ 62081 <br /> ■ - - - - © ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />