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A <br /> W Waste Tire Suy & Inspection Reportinspection Report Number <br /> - _ ■ <br /> State of California <br /> 181 <br /> eSurvey Form - Page 1 j_ a v 2 5 6 9 4 <br /> California IntgratedWastManagementBoard i <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> u 2 97 <br />� TPID- Inspection O � I � Inspection Type (Fill one) ' <br /> Site Suffix: ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> = <br /> Identifier: ' <br /> , L"A�^ ( � ti, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> _ — <br /> 4'_ <br /> Business or Facility Name <br /> " Inspected By Inspector <br /> Till �i <br /> Physical)Address ( r Lli� �_ i ' <br /> SUbel- <br /> �Ir,C1� t �`.,A �� � Z� � � Inspection Date City - State ZIP Gude Time In Time Out <br /> ------- _..-.------._-._ <br /> 0 AM <br /> Business Rep Title1 L O AM <br /> l r f <br /> I— Ljopm E-1- 0 PM <br /> t �, ;] <br /> t.Operational Status Business Role r <br /> 71 t+ (Fill one only) ( isp� I Fill all that apply) <br /> Fh� t <br /> J,• k" w• ' r ":i� ,rn �. i <br /> Q Active � 1��` F Y� �'Generator <br /> — <br /> � 0 Closed <br /> Haller <br /> E-EdlfG���'It(+r�'���ar✓e"�M"t�'r+rt�`�ar <br /> 01, <br /> pait <br /> Inactive <br /> Longitude - 0 Planned 0`OTl H Mr nxr� 0 End Use DContamer <br /> ((( <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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 III / m <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 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 /> Q 1 0 Other: § <br /> Comments <br /> r—CA('If I ��� i' �'t,� f i ,�' ln� 1 rr,7; ✓i ��Jfl`.� /)✓ _�� /�.r /C — <br /> 1✓<` `Y)�fit_I f`t �. > id I%u?t �' (�,�i �JT lei /�i C�tU�I - <br /> iobI,-1V)Ie 19Cc� 1Qe vL)P,\ i;4 wtn,,Jb [(-I/,P0 f)f <br /> Inspection Form Included: (� �.4n+N �, w w?f r °,c�"Yr� 7r° n'fir, ,'+y^��'orf;M+;n+�a'{�' ti[x� �"�fFv '+. I'{ s �a ',dlt'nr�sr ,sk , 7rr>�io", 5�'} ,,t,ur °�P <br /> tJ <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X � l r A ,pry, I_ i � L 62081 <br /> ■ -- �� Copy: I l: <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> I <br />