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Waste Tire Suy & Inspection Repart 'lnspection Report Number <br /> State of California -- �- <br /> `azsa CIWM61S1(New 04/04) <br /> Survey Form - Pagel 2 fl 7 3 <br /> California In Waste Management Board - <br /> Part A- Survey r BLUE OR BLACK INK PEN <br /> TPID- - L7� <br /> Inspection Type (Fill one) <br /> Site Suffix: , j n ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �'` -j If Referral,choose referral type'(Fill one) <br /> Identifier: �- 0 t A Ln Gt ,.J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �- <br /> Inspected By Inspector <br /> rr` <br /> Physical <br /> Address <br /> Street La tf1C*�J,,- Inspection Date Y � M � <br /> Zi <br /> City State Cocje Time In Time Out <br /> Business Rep Title j 0 AM f \ �.-� AM <br /> Lj 0 P 1� �` �) 0 P <br /> 6perational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply)'ll. (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> PSLatitude DQ Closed Q Ale <br /> GCrkedr <br /> Q Hauler Q Indoor <br /> Longitude ® Inactive Q TruOQ Planned Q T7 End Use Q Container <br /> {gl ,ype (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Z 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 O Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O 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 /> M / M / m <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire HaulersQ Referred/CIWMB Enforcement <br /> Q O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators i Q In Compliance - No`Violations <br /> O O Other: § <br /> r H; <br /> Comments10�41 f tq," ' <br /> 1 J SIV 1 Q ,~ V <br /> c � <br /> Inspection Form Included: <br /> p O', <br /> Comments Included. Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X �i d..; A, .1,". a. I <br /> ■ _ _- <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />