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Waste Tire Suy & Inspection Report Ins on Report Number ■ <br /> ( g) SurveyForm - Page1 ; 1 8 - 1025884 <br /> California Integrated IVWaate of steManagementBoard - - - ? <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> If > Profile <br /> TPID- Inspection Type (Fill one) <br />} Site Suffix: <br /> 0 Routine 0 Re-inspection V,-'Observation <br /> fl <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: �W l y'( U((C I{t (�(i( f L 'c Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> PhysicalAddress <br /> J-C Mill I Z_ <br /> Street <br /> -' Inspection Date <br /> City State ZlP Code Time In Time Out <br /> Business Rep Title OAM AM <br /> m �OPM m � 0 P <br /> t- -- - <br /> L Operational Statusr Business Role k r„ <br /> 1 (Fill one only) tfI SII ka � j (Fill all that apply) <br /> ✓.Pp � .., ^;� t � � �J ai>`I a#5. +��� rd r,�f�re 4t���iE�" �'�,; <br /> I® Active Q Generator <br /> PSLatitude 0 Q Closed <br /> G <br /> � <br /> Q Hauler ' <br /> - 0 Q Inactive <br /> Longitude - <br /> 9 0Planned End-Use <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> I <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler ® Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A i HAULING AND MANIFEST REQUIREMENTS <br /> -- ---- - -- - Q 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 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> (Required for NOV or EXT) <br /> Q 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/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities -_ <br /> Q 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 � fir) tty �Yt ty U <br /> - — <br /> k•10 f t T I r o o t )1 e-t-Th <br /> Tl1ic, 7rt('( (14 a', !-1CrIf,'t, I Ii.tI/(, ti. f_,C <br /> Ct U(7 <br /> r , r I r a I'1 <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:410 Incorrect: X ": X A M, L, 1 1 - 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> r - <br />