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l� Waste Tire SUM & -Inspection Re o, , Inspection Report Number ■ <br /> x . `•L€iii`. State of California y r <br /> iiia CIWMB 181(New Manage) Survey Form - Page ..1 �� 17, .- 1 0 7 3 4 0 0 <br /> California Integrated Waste Management Board 4 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ! Inspection Type (Fill one) <br /> Site Suffix: Q Routine 0 Re-inspection 0 Referral Observation <br /> Local - — —: - - �--- -- - -"---- — If Referral;choose referral type(Fill one) -" <br /> Identifier: 1 ,� _�r { �� t is j��.. i 0 CHP.- 0 CIWMB 0 Complaint. 0 Educational Visit 0 Other <br /> Business or Facility Name U <br /> Inspected By Inspector <br /> Physical Address J n - ( aJ111It- <br /> Street <br /> �,1� Inspection Date <br /> (r <br /> City l• > -State ZIP Code. l Time In V Time Out l <br /> Business Rep { Title m : m O PM m ' m O PM <br /> ("% I� 1I�011Ct �l � t .('C4trtitCt£t v� , <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I ' f r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I_ I Q Active 0 Passenger (5 Generator 0 Outdoor <br /> D 0 Closed 0 Altered <br /> GPS Latitude , m� 0 Hauler 0 Indoor <br /> D 0 Inactive q!) Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use Qi Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 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 I I <br /> .' <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V —Ai 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 / IE / 11:1 <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enfo dement <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 - <br /> Q In Compliance - No Violations . <br /> 0 0 Other: § <br /> /1 /a L f <br /> CommentsF(le 6o/4,q L, P/_J_uc � <br /> e <br /> pp C•�, j r / IPA <br /> /� r y� f t <br /> a .�o 1 1 k.(s J t�i((� 1-.I f LV k/J6 i { l Fr f l t C !f a t �( l �� ( ��'i + <br /> i <br /> yJ tc <br /> Inspection Form Included: 0. <br /> ! ' ^ T <br /> Comments Included: 0' ....... ------ <br /> i .. <br /> Business Rep's Signature Phone Number Inspector's <br /> Signa(ture r Phone <br /> r <br /> one Number <br /> (� U,/ <br /> INSTRUCTIONS ON BACK Correct:� Incorrect: ( ? �/ EA .f4MP ;LE11127T3 <br /> White Copy:CIWMB Yellow Copy:Operator. - Pink Copy:LEA ■ <br /> s 1 Ja <br /> J <br />