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:: -A Waste Tire Y & Inspection Rep <br /> Inspection Report Number <br /> - <br /> State of California 1 Ai R <br /> California Ine grat df81 Was eeManagement Board Survey Form — Page <br /> age 1 1 7 - { O 13 U L V <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Inspection Details ` <br /> !PID- Inspection Type (Fill one) <br /> Site Suffix: , �� �, J 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: ;fit ( l VQ C y} oil-A,i EA 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector, <br /> Physical Address 11 <br /> 16 er 10c) <br /> Street <br /> n +, C Inspection Date <br /> City State ZIP Codi Time In Time Out <br /> Business Rep Title LTO AM FE L__7 Q AM <br /> J, �q. O PM O PM <br /> I Operational Status ire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) T <br /> Q f� (Fill one only) Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> V ®Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude <br /> O 0 Closed 0 Altered <br /> m . <br /> GPS Q Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR Q End-Use <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 Hauler0 Agriculture 0 Shredder (9 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <br /> 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/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 0 Other: § <br /> Commentst�'+,, { r f �{ (' r <br /> 'ilIf�th' `, <br /> rI �r�lc��g� c� of wr,(�.<< l ��rc� �o � OL& �i' EJ �ourC�P �e r �n <br /> �1c1 yr ra« Iii l.�if Pr� o���✓ ►ii}� i�) .f�rrr e c{�d bc��ia�,C r� ,� �.f �<i� <br /> pection Form 'Inc u e.: w•w , . f <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> /_ 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: /\ ��i X A ;°, P L 1 2 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />