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Waste Tire Sy & Inspection ReporInspection Report Number ■ <br /> -- - <br /> �"`.^� State of California U01 <br /> CIWMB 04104) <br /> i A¢ tf�' �' ]�(y i <br /> California Int grat d,81 Was eeManagement Board Survey Form - Page 1 -� J 1 Y 315 4 8 <br /> Part A Survey BLUE OR BLACK INK PEN <br /> d ., !ry"h,w,�r,„x im as � �""' rAr,« ": ,{'✓!��" ty�r b' "�,1w' t"� 1i, "F '"E';f.'P J^»"" :l° ;,, ^'+ y�,,�y'' <br /> rww"a >m � ridpr" i'. "F�" ,nM",,"iror t ��1 <br /> e 0 .W.,,,uv «, � fPA <br /> �...._ ...._ I...._._.. - <br /> TPID- r_ Inspection Type (Fill one) <br /> Site Suffix: t 1 0 Routine Q Re-inspection 0 Referral 0 Observation <br /> — - - <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: I s e I + <br /> 1�— t�(' ✓ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address -d f /� � '( , i!Ltd- <br /> Street 1 Inspection Date V l / =� t <br /> Ins <br /> City State ZIP Code Time In _ Time Out <br /> Business Rep Title A <br /> O PM O PM <br /> LE 1-1:1 <br /> . . <br /> I dj 0 <br /> l., I. Operational Status `r Business Role Stora e Type <br /> �mw "� g Yp <br /> (Fill one only) (Ftl!X11 thkply (Fill all that apply) (Fill all that apply) <br /> „ (a Active '6(�� � �r �"� 0 Generator 0 Outdoor <br /> r <br /> Latitude 0 Closed '' Io^y"tf" ) <br /> GPS 0 Hauler 0 indoor <br /> O 0Inactive rCPi uy%)y <br /> D.pT0 End-Use ,Container <br /> Longitude 0 Planned R I <br /> R <br /> 7��W a �.1197,,�i,*r.,,;�l <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 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder (a Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A T HAULING AND MANIFEST REQUIREMENTS <br /> 0 00 Notice Of Violation 0 Extension <br /> 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 Manifestingequirements- Date m <br /> 0 0 14 CCR§18459.1 (a)(b) (c)-Tire Program ID Number from CIWMB m m <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 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/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 /> r', <br /> Comments ' <br /> It <br /> dej lda (,, ( / l <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: X G�, ,; ;u; y", ,=` i._ L:., � "=: <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />