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Waste lire S&eyInspection Repo# In&tion Report Numb--r <br /> •'®II9 State of California <br /> CIWMB 181( e ) Survey Form - Page 1 i._ 8 - 1006688 <br /> California Integrated WasttManagement <br /> Waste Management Board - <br /> Part A BSurvey. BLUE OR BLACK INK PEN <br /> ,ww• .u1 ;11; { t d <br />} TPID- Inspection Type (Fill one) <br /> Site Suffix: (� �ff j { <br /> O �' �! ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: b1 J(` (,t 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> -- - <br /> Business or Facility Name Inspected By Inspector <br /> C" <br /> Physical Address `^ —T— L J I 1 J '�l <br /> 7I S vt/i F�- �,'�a L� - <br /> Street L0-� <br /> Inspection Date lSvc k--t0 r-) ,(') It? i1 <br /> C– - <br /> City State Zip Code Time In Time Out <br /> Business Rep Title AM Q AM <br /> [�&'_O <br /> 0 PM <br /> : ® PM <br /> !� Operational Statusiul <br /> h Business Rolex <br /> ' O (Fill one only) (Fill all that apply) II (p( a apy+ <br /> ® Active Generator ( t� t�r <br /> Closed <br /> �+ <br /> Latitude ( % dd GM 1d' nids,itta(p'RFf"Ir,'�S J;w )�i <br /> GPS ��i/ kry� 7 0 Hauler j)fKtJp �� r I <br /> __.0 0 Inactive <br /> L 0 Planned itude 0 End-Use Ck l )nar i'r <br /> 0 New Tire Dealer 0 Auto Repair Q 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 I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VVI A HAULING AND MANIFEST REQUIREMENTS <br /> 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 m / mFTI <br /> 0 0 114 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 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 i 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance No Violations <br /> 0 0 (Other: § <br /> Comments -1 C <br /> Q1',� fL 1; L'�t:f1 �� (?✓y iCf- V'ri ;( f(t(Li CKs a p,d l U Vit(Z(o f f.L� -t b"l;r c [C {- 4-v ` -I i V I t{je 1 <br /> i a(�ry'iill,i1 li�C CY Le �C111'kj( , <br /> _ 0 <br /> il. n1', �d l al°y R'n y/�yyylll���; • t�SrMa M ��"ry tl9a <br /> INSTRUCTIONS ON BACK Correct:* incorrect: i_s."s 62081 <br /> k ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />