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■ Waste Tire SU, & Inspection Reportspection Report Number <br /> Numb <br /> -- - - ■ <br /> State B California 1 3 3 5 2 <br /> Grnia Cgrated Waste <br /> Survey Form - Page 1 {V� <br /> California Integrated Waste Management Board � <br /> Part A Survey <br /> 77, BLUE OR BLACK INK PEN <br /> r � �,_" �a }n�r', �, nYrry r, r r orf r� �� TMea r,rwv""r;t,1� r � � ✓r "r nr�w e .� rs,°%: v s r f + t r r r y <br /> NKr 'dU, <br /> i <br /> f TSite Su �PID- Inspection Type (Fill one) <br /> ffix: <br /> 1 � ( -�' � �� �i � r""� � (4 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: n z >' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - -- -- - - <br /> Inspected By Inspector <br /> Physical Address - 71 _e;� <br /> F I L <br /> _ <br /> I_ J° <br /> Street <br /> rr- Inspection Date j (7 <br /> Cit ' ' Time In Time Out <br /> Y w State ZIP Code _ <br /> Business Rep Title _ 0 AM 0 AM <br /> ® PM ' � QPM <br /> Operational Status ifir r�Z Business Role <br /> (Fill one only) Rt' ►rn � (Fill all that apply) <br /> ry ;+ ( Active Z "?Igr' " Q Generator <br /> PSLatitude C.�( Q Closed <br /> G {���Q�' <br /> "r <br /> i� Q Hauler <br /> Q Inactive Q, tf � �iri <br /> 0 <br /> Longitude - Q Planned nn�)")'rr Q End Use ^�( cS` �frr <br /> r Arr 6 � r 12va l r u r ✓r y;. rr / ry "„"M rY b r 7F r <br /> . :...,_,_.. iifr�.�.�.n,r,�-b_ ,�r.,7.-: r ." .a��:4R r�.._a.,�,,•. N" W w 'r ( _ "rr" ;� <br /> � <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 1 <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 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 /> 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 E)M <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 /> 1 <br /> Q Q Other: § <br /> Comments <br /> _ -� <br /> i <br /> .n,,.v... " r r,'t, t,:wr r ,,'•,:. a .F"` r.;r � 6 ;•� k ""I rr".,f r'r I � "c��p rrw�°f"w»"( �/ r.n ~G � rri 7 ,,M n.; �(:" r r..7nv v�rlr <br /> i ' J d � h"J _`r4"'„'r'` re¢rr��y ",�"�,.� *N .✓, �t�` ,w�n+ar,Y" z� 1r�, � .u- <br /> _��w_ . ,r 8u �rNe Rep s,S( natt�re PhoneNumberrispd `s Iu r " "�fi pya ' Ict ►er <br /> INSTRUCTIONS ON BACK Correct:10incorrect: X ; ', A c r , 62081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />