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== <br />W017 <br /> aste Tire Su&y & Inspection Repor* Inspection Report Number <br /> LL: <br /> CIWMB California t81 ew 04104) 1 - 1 0 1 3 ! 8 5 <br /> California Integrated Was Waste Management Board Survey Form - Page 1 __- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- r' Inspection Type (Fill one) <br /> Site Suffix: (-� 7 x� - U <br /> _ 0 Routine QRe-ins Re-inspection <br /> Q Referral Q Observation <br /> Local c"\ If Referral,choose referral type(Fill one) <br /> Identifier. ,� {, , Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name T <br /> r- E. Inspected By Inspector <br /> Physical Address <br /> jr J -J <br /> Street i <br /> Inspection Date <br /> a �' ;)t� W <br /> Time Time Out <br /> State ZIP Code ' <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Roletorage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) Fill all that apply) <br /> Tire Count (Whole/ 77 \1 <br /> Q Active Q Passenger Q Generator -Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude W - � � � � Q Q <br /> Hauler Indoor <br /> O Q Inactive Q Truck <br /> Longitude - 1 Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 /> M / M / m <br /> Q Q 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/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q in Compliance - No Violations <br /> Q Q Other: § <br /> Comments ;� .l tl i{'(` ;r I &tcl ce. <br /> 7G t"r 7Ctse a(e j t e ' r' (/(L C `!"b r r N l P. I t r� `,� ✓tC <br /> I i i0f�,Lr �'� 1&4h f)() (V- C( y o t( ! (j r"1 `7-1 �w ( <br /> 71 <br /> tri' li! ( i; I -f '✓ �c(r <br /> Y I Inc <br /> Inspection Form Included: <br /> Comments Included: Q J (_ <br /> Busitless Rep's Signature Phone Number Invector's.Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X F_=� X A. ;S P I L I E 1 11 2 3 <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />