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is ection Report Number <br /> Waste Tire Su & Inspection Re ori pp _ <br /> i i® 6 State of California <br /> CIWMB 181( e ) Survey Form - Page 1 ± j 9 - 1006301 <br /> 1 <br /> Cahm <br /> fora Integrated WasttManage <br /> Waste Management Board <br /> Part A Survey BLUE OR BLACK INK PEN <br /> 4t [Io1} tldd A«ryk 5dq(b,1 / 7# aciYA?1lA . _ �_� _ <br /> t.,�sa+ _ e¢s"] .:,...u 9 .✓rr,✓ � ✓ u'✓ r✓d !i r r r��ha.✓r <br /> TPID- - Inspection Type (Fill one) <br /> Site Suffix: (0 Routine Q Re-inspection Q Referral Q Observation <br /> Local t, / If Referral,choose referral type(Fill one) <br /> Identifier: 1✓� �. 0"Lt v. `� +; <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address - ! ' J <br /> r _ _ <br /> Street EcE <br /> r_ Inspection Date <br /> -1 1.1 1'.) 2 i <br /> City State ZIP Cade Time In _ Time Out <br /> Business Rep Title O AM Q AM <br /> m <br /> �^ �} 0 PM QPM <br /> yr <br /> Operational Stat us )r I� } r a3 r +; Business Role g � <br /> Fill one only) wy y s W <br /> ( Y) �� �I �t ��( , (FIII all that apply) <br /> Q Active I,"�( ���t Generator <br /> , <br /> PS Latitude <br /> Q Closed <br /> Glyd" 41 r�li�er��,�✓d+,d4drwr`�it��'�'^ rt✓�,m,rnr�dt�[�'�I��w��✓d✓"���� 44��,' <br /> '. <br /> Q Hauler � �dYW a �wy�✓d✓aN <br /> Q inactive t"r�^ <br /> O <br /> fiVr I <br /> r' <br /> � Q End-UseLOngltude lannedQPs r sr gar <br /> �� ,,.,, —`' ✓ wr�,��nn�""r�rr�'�,;& � "�r ✓y�� �n�✓""{+��w✓a�t�f;(.1.�� �:',� •,�u'.I � r �° M >i •r.. a �fi7✓a ✓�:' r�r 7d ro . � ;lyre r a. dui 3d T +^'✓a v drr r� ✓ <br /> ..+nt y + ✓ � ''.«y. _,dv, Y f d , ✓ ✓,.; rlrrr.✓.. ,i: 7i d dT;M>ir rt;,.✓ ii tt + w✓ x n ski+ rt''✓ iC d '� �✓re✓a°rid «�`✓ rvr✓r, !w dpi h ✓ t` <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 REQUIREMEE S <br /> @ 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 / <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days I <br /> (Required for NOV or EXT) <br /> ® 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 f CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q'In Compliance - 'No Violations <br /> Q Q Other: § <br /> Comments <br /> I tl)t 4 Lt _ f (. ( if i t �F> <} 0 t <br /> 11�' %irk ril `j'j (,dtirtJCti _Cif1 �F t,�f" t "' � y`i'1('' G 1 , i�<C11(`L1P <br /> aI Id ILI C(`(;`�, In�l�— `ICa11tFr-17A �E'CL�(C1 _ I. I(t ll LP F J(k6lffl ej�l <br /> I I It ! <br /> >Fcttvvl. NOV nir7710 <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X A�, \/ (: ;;a A ,0`1,1 P i �1 L d � 1 I 2+31 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />