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_ Waste Tire ley & Inspection Rep Inspection Report Number <br /> FFFI State of California _ <br /> CIWMB 181( eSurvey Form - Page 1 LI 1 0 7 ' 8 8 5, <br /> California Integrated WasttManagement Management Board -- ---• <br /> Part A- Survey BLUE OR BLACK INK PEN <br />} TPID- Inspection Type (Fill one) <br /> Site Suffix: ' IS1 -71 0 � � 1 Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral.type(Fill one) <br /> Identifier: 5or) J_0 CIC{t t\ o G 00T)A 0 CHP 0 CIWMB 0,Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> nn 1 e,C�:. <br /> Street <br /> Inspection Date <br /> ! (::� C-A Time In Time Out <br /> City State IP Coe _ _ <br /> Business Rep Title [--F O AM m Q AM <br /> W O PM �l�l O PM <br /> b l - <br /> The C. ( (Fill one only)onal Status (Fill ireType Business <br /> apply)', (Fill all that apply) <br /> SFilllrage l all thatyapply):: <br /> e <br /> ount Whole/PTE <br /> 0 Active 0 Passenger (0 Generator y) 0 Outdoor <br /> Closed 0 Altered <br /> 0 <br /> GPS 0 Hauler 0 Indoor <br /> Latitude <br /> O � Inactive Q Truck <br /> Longitude — ' I � 1 Q Planned Q OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q 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 Q Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 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 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 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive 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 /> Comments ✓ �^ l y j <br /> — 07h .--1 ion �' r?r71 '�: LAlC —*-)ed n I',{1u►nn <br /> IILlli s IJJCIC� ���25 to S �Y ��tP <br />' s <br /> Inspection Form Included 0' <br /> Comments Included: 0 <br /> Business Rep's Signature lPhone Number' spector's Si natu Phone Number <br /> r 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X j XJ A MFF ; TIC 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />