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Waste Tire & Inspection Re Inspection Report Number <br /> Y p p _ - � <br /> No <br /> State of California <br /> rCgrated Waste <br /> Survey Form - Page 1 i � - 1 0 0 0 4 0 7 <br /> California Integrated Waste Management Board ---_ _ -_._ <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> � <br /> TPID- f Inspection Type (Fill one) <br /> Site Suffix: ,, RI <br /> 7 / 71U 0 Routine 0 Re inspection 0 Referral 0 Observation <br /> Local _ Y If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> i <br /> Physical Address <br /> Street _ <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM AM <br /> LEJ M <br /> © PM I�� � 0 PM <br /> y. <br /> �i ai t <br /> Operational Status � ,f��1 yM,�ly,`�r„�usiness Role <br /> t (Fill one only) Fr" �I11� �, (Fill all that apply) i <br /> r �r w Ei <br /> 0 Active i 0 Generator '( v <br /> Latitude <br /> GPS C 0 Closed <br /> 0 Hauler <br /> 0 Inactive � <br /> Longitude 0 Planned ,+� i � 0 End Use <br /> <�US111eS5`T <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 i <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation 0 Extension <br /> 0 0 I PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 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 (a)(b) (c)-Tire Program ID Number from CIWMB <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 Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 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 0 In Compliance - No Violations <br /> 0 10 Other: § --- - -- - - <br /> Comments <br /> c , r <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number _ Inspector's Signature Phone Number <br /> / ry 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />