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Waste Tire Sdftly & Inspection Repo Inspection Report Number <br /> Stateof81(Nrrne Survey Form Page 1 i - 1 0 l <br /> California <br /> CIWMB 181(New nage <br /> California Integrated Waste Management Board ----- --- _0_1— �-- - -' <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> 101011Ses �r .. <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: l ,J (D Routine 0 Re-inspection 0 Referral 0 Qbservation <br /> Local i } If Referral,choose referral type(Fill one) <br /> Identifier: 1 ( / ! 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name f" Inspected By Inspector <br /> I <br /> Physical Address — I ^� <br /> ITT <br /> Street r Inspection Date <br /> �---- � i Time In Time Out <br /> City State ZIP Code EII : <br /> � _Business Rep Title � AM � AM <br /> Et.J 0 PM ---�---- O PM <br /> Operational Status Tire'T + i yr�t( a"r Business Role Storage Type <br /> (Fill one only) (Fill all to t, (Fill all that apply) (Fill all that apply)' <br /> r wr <br /> 0 Active 0 Passe 0 Generator 0 Outdoor <br /> O � <br /> Latitude ® Closed Alterai(r„ <br /> GPS Hauler indoor <br /> LL_���11���JJJ � �"t�' <br /> Q Inactive 0 Tl uck <br /> Longitude — �0 0 Planned 0 OTR yrs f 0 End-Use 0 Container <br /> 4ussness"fype (Fili 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 L <br /> -- -, <br /> Part B - Ins action of Waste The Dealer, Generator, Hauler and End-Use FacilityENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS .. <br /> Inspection _ <br /> -- --- 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 /> M / m / 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 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 /> 0 0 Other: § - -- <br /> Comments <br /> f' � C I J.✓ r I I " �t. � . / � I �1 t t' 1 { _ ___I _ „— - f � f t I <br /> ��a"r �� Pw a� w� tilAx4?aC*t� ^�,�'"� >,' c`.; "Ww&� °! Y g, wv�':� p0` �' ✓��, w i <br /> �;I�;Gi r ".'x.� �.:.�cer`.r +�:. ���. �„�+! _�����" ���.�...",w��a e,5,'rf, �iw";:t ' ..brr aw mr ,". „,,� w t� •�'�r,::,i�w„^��' '� � �'� °�.'� <br /> INSTRUCTIONS ON BACK L Correct:* 'Incorrect. 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />