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■ y p p inspection Report Number
<br /> 1�las°te Tire Su : $� Inspection Re ort
<br /> State of California -j -
<br /> ®� CIWMB 181(New 04/04) Survey Form - Page 1 1 - 1 0 1 3 >t 69 _
<br /> California Integrated Waste Management Board
<br /> Part A Surve BLUE OR BLACK INK PEN
<br /> pectirl'��Ili
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<br /> TPID- �0. Inspection Type (Fill one)
<br /> �q ?_ � r ® O P O O
<br /> Site Suffix: : X t �% 0 Routine Re-inspection Referral Observation
<br /> Local r If Referral,choose referral type(Fill one)
<br /> CIdentifier: 0 CHP 0CIWMB OCom taint OEducational Visit 0Other
<br /> Business or Facility Name
<br /> Inspected By Inspector
<br /> L_._ `l f /
<br /> Physical Address ( t i �lr�b';_(_ I.t,(?
<br /> Street
<br /> Inspection
<br /> ITC -66-1
<br /> ection Date
<br /> City State ZIP Code Time Ind Time Out
<br /> Business Rep Title 0 AM 0 AM
<br /> O PM O PM
<br /> L jrI L. r 1.1 s ;r k.
<br /> O erational Status Business Roleq,
<br /> (Fill one only) f(t1( tIiJ (Fill all that apply)
<br /> 7 r h r! ev��� �, *'i�±''r,,',� t !min ✓�1��,,t ,�'
<br /> 0 Active e t QQ Generator i, �dCR w
<br /> s �"a�'a� l s✓��k�,'
<br /> Closed r r <
<br /> GPS Latitude ED 0 1 ar � r
<br /> ,d� Q Hauler IWuP i
<br /> 4
<br /> (D Inactive r
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<br /> _ a i
<br /> r ,rr���A,,,„„„rc rwr 0 End Use i �tpfo111���`S
<br /> Longitude — � 0 Planned IY�� GiG �� � .���f%
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<br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet J 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 ( Other 41"H ( f'{t !r i (?
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS R`
<br /> ;V A HAULING AND MANIFEST REQUIREMENTS 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 /> PRC§42956-Registration/Decal in Vehicle
<br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m 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 0 14 CCR 18459.3-Retention of Manifest Forms and Tire Tri Logs for 3 ears -
<br /> O O § P 9 Y I ^
<br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement
<br /> 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 In Compliance - No Violations
<br /> 0 0 Other: § -
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<br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X I�' r�, �W t �� 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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