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Waste Tire SLPJ&y & inspection Report-Inspection Report Number ■ <br /> ■ W <br /> StateofCalifornia SlCIWM8181(Newl'04/ <br /> _1 Survey Form - Page 1 1 3_-B 1 0 1 0 0 3I .6 <br /> ""California Integrated Waste Management Board - ----- - -- - - - --- - <br /> Part A- Surve _ PE <br /> _ Inspection Type (Fill one) <br /> Site Suffix: lid �L` 5 (% Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local J f If Referral,choose referral type(Fill one) <br /> Identifier: �l _J 00 f +s,I (�i/t -•1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name '" Inspected By Inspector <br /> _. �� I' / of L <br /> Physical Address y — _ _-s_�___�s / "� N; 1 �✓r�-� <br /> Street ,` Inspection Date <br /> A 0 <br /> City State ZIP CodeJ' Time In Time Out <br /> Business Rep Title O <br /> AM <br /> O PM OPM AM <br /> Lar,1 '✓i S, ) L � ff F__ L <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply), <br /> Tile COW-it (Whole/PTE) , <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS <br /> Latitude M - H� Hauler 0indoor <br /> �0 0 Inactive 0 Truck <br /> Longitude — + Planned 0 OTR End Use 0 Container <br /> ' I <br /> 777 <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body @ Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I <br /> I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> Vi A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 ' O - - <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years j <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <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 0 In Compliance - No Violations <br /> 0 0 Other: § __�_,-------- --------------- ---..___._._____, - <br /> Comments <br /> in. � -1 � <br /> - ! `� r <br /> !� 1� - v 1(2/11 P;:( 47 U 10- L.{ C 1 CJ{ �1 t :L t r.,l t�ft {.)1 <br /> Inspection Form Included: 0' <br /> Comments Included: 0 - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: , <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />