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Waste Tire Surey & Inspection Report onspection Report Number ■ <br /> �Eu State of California <br /> C,WMB181 <br /> Survey Form - Page 1 11 - 1088356 <br /> California Integrated Waste Management Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Business Prof�luy'f, 'fV Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: J' Fe, k�� T� ,� �� - � (�.f ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ---- ' i — If Referral,choose referral type(Fill one) <br /> Identifier: <br /> r, / <br /> a_ _ y'Z tit jl iit;� i•i 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name , ' Inspected By Inspector <br /> c <br /> Physical Address tctl <br /> Lt <br /> aI0 +,ev (rL-.t rt"o ,� 9 <br /> -�1. <br /> Street <br /> Inspection Date <br /> ` - Time In Time Out <br /> �%y �-__.---------State L!P(Jodi _ _ . <br /> Business Rep Title — 61 <br /> 0 AM [ 0 AM <br /> i1 / <br /> I — , -(( t t _—�L-` V1 _ Operational Status Tire Type _T <br /> Business Role Storage Type <br /> •e-- (Fill one only) (Fill all that apply)! (Fill all that apply) (Fill all that apply) <br /> Fire <br /> di <br /> op(INhe/PAl <br /> 0 Active 0 Passenger j' 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitudeg' [I] <br /> . �� 0 Inac0 Hauler 0 Indoor <br /> p Inactive 0 Truck <br /> Longitude � 0 Planned 0 OTR <br /> _ i 0 End-Use 0 Container <br /> _ _ I <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 j 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 m m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive 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 /> 014 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 /> Other: § - - - JJ- <br /> Comments j`•(t t`1 r 1 f �,. <br /> {C F_y C r yl r - <br /> r �+ C( C- { r- �Y.{�.. GF,�I { j Y;'�'(•'•;� ��.�bl.� +�.J�f Ci��' �! 1-��C(�I'Ylfb; F-} )��� (` �� � <br /> m(/ LA <br /> 1 <br /> I <br /> Inspection Form Included: 0' r <br /> Comments Included: 0 Business Rep's Signature Phone Number Inspectors Signature -- <br /> ._ I <br /> hone Number , <br /> INSTRUCTIONS ON BACK Correct: Incorrect: /p ^ X k62081 <br /> I� e White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® S <br />