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■ ., Waste Tire Sufty & Inspection Repor Inspection Report Number <br />State of CaliforniaCIWMB 04104) <br />,. j^� A n j({� i. <br />California Int grat d181 Was eeManagement Board Survey Form - Page 1 8 � � y j�yf � 0 7 4 8 <br />Part A - Survey BLUE OR BLACK INK PEN <br />TPID - <br />Site Suffix: <br />0 Dismantler 0 Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />Station 0 Hauler 0 Agriculture 0 Shredder a Other <br />Id <br />_ <br />` <br />��� <br />I <br />HAULING AND MANIFEST REQUIREMENTS <br />Inspection Type (Fill one) <br />0 Notice Of Violation 0 Extension <br />0 0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 0 <br />{y. <br />II <br />Compliance Deadline <br />0 0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />(D Routine <br />0 Re -inspection <br />0 Referral 0 Observation <br />Local <br />rLIZ <br />If Referral, choose referral type (Fill one) <br />Identifier: <br />yt ;; <br />r <br />, j <br />0 CHP 0 CIWMB 0 Complaint <br />0 Educational Visit 0 Other <br />Business or Facility Name <br />Inspected B <br />p Y <br />Inspector <br />0 0 <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />1 <br />- <br />Physical Address <br />0 0 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />(Required forNOV or EXT). <br />0 0 <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Inspection <br />Date <br />0 0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Street <br />rl <br />Q In Compliance - No Violations <br />0 0 <br />Other: § <br />--- =-- <br />Comments j(t^ c" ); , f <br />1 ' J <br />f;. l "f <br />�J <br />,r• �' v t,. �(✓'-/ i!-fk' � i!`' I � s �j��.t_VZ"lt��'. 1 / t i / <br />lL( <br />-ir <br />ity r , <br /><<. U! } oi.." � ftr � t' r, fav/.v i <br />State ZIP Code <br />Time In _ <br />Time Out <br />Business Rep <br />Title <br />n 0 AM <br />AM <br />0 PM <br />[-10 <br />0 PM <br />Operational Status <br />(Fill one only) <br />, ¢ , t,r� � � <br />it �� <br />Business Role <br />(Fill all that apply) <br />0 Active <br />��� <br />0 Generator <br />Closed <br />GPS Latitude <br />. <br />�? <br />0 Hauler <br />L ongitude -� <br />. <br />C 0 Inactive <br />0 Planned <br />�� <br />0 End -Use <br />I r; <br />f d <br />0 New Tire Dealer 0 Auto Repair (f Trucking Fleet 0 Government 0 Retreader <br />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 <br />Station 0 Hauler 0 Agriculture 0 Shredder a Other <br />ki.i , r ;(ry � ,r 'n' Astir,( > <br />- <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V 1 A <br />HAULING AND MANIFEST REQUIREMENTS <br />0 Notice Of Violation 0 Extension <br />0 0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />0 0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date <br />0 0 <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 0 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />(Required forNOV or EXT). <br />0 0 <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 Referred / CIWMB Enforcement <br />0 0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q In Compliance - No Violations <br />0 0 <br />Other: § <br />--- =-- <br />Comments j(t^ c" ); , f <br />1 ' J <br />f;. l "f <br />�J <br />,r• �' v t,. �(✓'-/ i!-fk' � i!`' I � s �j��.t_VZ"lt��'. 1 / t i / <br />lL( <br />-ir <br /><<. U! } oi.." � ftr � t' r, fav/.v i <br />µ�„rhk�e r >,�u rrrs "'dd mh„W„ a5[ a�,r Ir "a; r Her f Na rF 91^ ,,. a; t Y arw f, ,r r wrr,° e�:"� ,.r r t/t rAr. 1 ".•'""C''; <br />Conlmen�r17 di ti wf W ,;r„rs wr> r. <br />t rr xBUSNiXe IZp`',I►�tlre° r.a as>Cru.. r�a�{ U IrytT ' x r'r p r y a 7 r v� <br />INSTRUCTIONS ON BACK Correct; Incorrect; i XI,a Mid I y L 62081 <br />__.._.�3_ <br />■ --- © ■ <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />