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Waste Tire Sur y & Inspection ReportIrispection Repor)'Number <br /> state of California <br /> k, ■ <br /> CIWMB181 <br /> asteMana a Survey Form - Pagel � � �1 3- - 1 0 -1 .3. 7 6 �2 <br /> California Integrated Waste Management Board ' <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ( � �} (� / (� ( Inspection Type (Fill one) <br /> Site Suffix: ' "j ;x 7 j & Routine Q Re-inspection. 0 Referral 0 Observation <br /> Local �-� k ( , If Referral,choose referral type(Fill one) <br /> Identifier:. JDAet \ K O CHP -0 CIWMB O Complaint O Educational Visit 0 Other <br /> Business or Facility Name U <br /> _ Inspected By Inspector <br /> Physical AddressEEI - }110 ++1 <br /> Street <br /> _ Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> r '` 1-1 0PM m • m 0PM <br /> l!✓ Q�1.' ! �i') �"t t_i7� l'7 �l{/I�i�}l`.tt� I - --- _•_- — <br /> I� Operational Status Tire Type Business Role J Storage Type <br /> Tire Count(Whole/PTE) I I t + (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) j <br /> @ Active Passenger (J)Generator. @ Outdoor <br /> O O Closed 0 Altered <br /> GPS Latitude m • (3 Hauler 0 Indoor <br /> t7 0 Inactive ) Truck <br /> Longitude - t r (Z) End-Use e Container <br /> 0 Planned OTR <br /> Business Type (Fill all that apply) t I`{ <br /> O New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader O Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer O Auto Body 0 Car Dealer (a Collection .Q Crumb Rubber <br /> 0 Service Station 0 Hauler .0 Agriculture 0 Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> _._...-............... <br /> __...._. <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation 0 Extension <br /> O Q PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. 1 Compliance Deadline r <br /> O O PRC§42956-Registration/Decal in Vehicle ` <br /> vMO � <br /> /Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements•lDate / ! � / o (LQ Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal.of Manifest Forms and Tire Trip Logs within,90 days (Required for NOV or EXT) <br /> Q 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 f 0 Referred I iWMB Enforcement <br /> Q 14 CCR§18461--Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Other: § <br /> Commentsn t t- <br /> .31 i f r ` t�k l a t _ () ' it , J ,n: t Loo rlr0:� <br /> , <br /> //1 11001-1C%&-O pe0f6 �J ill OP? 4k .•�I�� t1i fe1� 50 Jwaspc [d✓ <br /> Lit"Ye (/1 1pCk-4d VI( <br /> I (` �iu 1 ( �UJ �1' f + r p f /It r. <br /> ri ri�t`.(� f � f 1 V 1 0� ,—G J1�E � , dE1C � 1� �.C?af'�� !"�{ l l ttLr1 <br /> V( ill ttE <br /> �i• I , rt r�- P"r ry 11 r b<-#J•t" � ;r 0i �,���_�v�C� _r��� IN off" . <br /> Inspection Form Included: ' t . t <br /> Comments Included. rti: t • . r : r 1. ; A. <br /> Business Rep's Signature Phone Number Inspector's?Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E A ,I!, P IL I E ' 111Z 3 f <br /> ■ White Copy:CIWMB. Yellow Copy:Operator Pink Copy:LEA ® ■ <br />