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Inspection Report Number <br /> Waste Tire Su y & Inspection Reports- <br /> State _-_ -_-- -- - <br /> ■ _� IIID of California <br /> CIWMB 81 tSurvey Form - Page 1 4 _- 'tt L -. V...__.-_J 4 <br /> California Integrated Wase Management Board <br /> . <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> TPID- -} Inspection Type (Fill one) <br /> Site Suffix: �-� - �1 Q Routine O Re-inspection Q Referral Q Observation <br /> Local (� ('� ( If Referral,choose referral type(Fill one) <br /> Identifier: r`i t ��ti`C.1(•�{ �. jj��y�. O CHP O CIWMB O Complaint Q Educational Visit O Other <br /> Business or Facility Name ) (L Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> r; 0PM � � 0 P <br /> _j I -7 I <br /> Operational Status Business Role Storage Type <br /> (Fill one only) ,' t �r ) I (Fill all that apply) (Fill all that apply)' <br /> ® Active �;,� ® Generator 0 Outdoor <br /> O li ��init �� rr <br /> Closed <br /> GPS Latitude i3�z� �' �t") pri � Q Hauler 0 Indoor <br /> Q Inactive <br /> Longitude - O Planned O End Use Q Container <br /> O New Tire Dealer 0 Auto Repair O Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer O Collection Q Crumb Rubber <br /> O Service Station Q Hauler O Agriculture Q Shredder 0 Other �( t I ( Jca i t <br /> .------- _.....-.--._._.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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / IT m <br /> Q 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 0 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 O In Compliance - No Violations <br /> 0 Other: § <br /> Comments ,,, ll 1 t I' l !' , +y Jzf a.c l;_ ✓ f / <br /> rN . oV 1 1 e l/1 /-. (,i/J f'f I E ) 1 f , <br /> �i)Lti';(1 � LLd (q LicIVt''� ��' ��r l Yi<:t F lf�' ^.)f �i'1 )vi P11�( ✓ ( 1l �' � •— <br /> /I�1� a h� +( ' <br /> (i <br /> 4 ) <br /> V v =tai 1 V ktC C tom' <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number inspector's,Signature Phone Number- <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �/ A M].P I ', I � 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />