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Waste TireAy8c InS e 0 Inspection Report <br /> p etion Rep p p Number <br /> State of California -- <br /> forn a CgratedMB Waste <br /> eManage) Survey Form - Page 1 - 0 5 7 4 9 <br /> California Integrated Waste Management Board <br /> Part A <br /> Survey - _ BLUE OR BLACK INK PEN <br /> p�Jss Profile Inspection Details <br /> - --- - <br /> TPID- _ / Inspection Type (Fill one) <br /> Site Suffix. <br /> Routine Q Re-inspection Q Referral Q Observation <br /> LocaiIf Referral,choose referral type(Fill one) <br /> Identfier. <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - - - <br /> 1 ` Inspected By Inspector <br /> Physical Address ` --� El <br /> I i 7 05\1':� YVI I <br /> Street <br /> I <br /> Inspection Date <br /> City Time In <br /> Business Rep Title Slate ode __.�.._]'Q~j AM / Time Out <br /> PM <br /> Q AM <br /> O PM <br /> ��_�.�...... 11 fir- <br /> Operational Status r�tl� t Business Role ': Cilr <br /> f Vn(Fill one only) -(Fill all that apply) �(rP <br /> y Q <br /> Active <br /> a -' �# (a Generator <br /> rmk 'ri <br /> D <br /> LatitudeED Q Closed l ( gQ Hauler <br /> Q inactive � <br /> O p le"�✓ <br /> Longitude - sty,v ,t4y h <br /> tQ Planned �,� `� Q End-Use � <br /> ^ � tR r�� °M <br /> Q New Tire Dealer Q Auto Repair Trucking Fleet Q Government Q Retreader Q Dismantler __Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 010 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other: <br /> Q In Compliance - No Violations <br /> § <br /> Comments <br /> y" 1, \\ � ^J✓L^�:4' _ � ''•fit/\.+'T �� _ - � 1�� f �J+ -:1/�1V11- <br /> e` 1— a i d PpjS — f j� P/✓ . — <br /> Inspection Form Included: Q ---- --- - —, <br /> Comments included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: 62081 <br /> ■ ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA <br />