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Waste Tire Sud6y & Inspection Repo *inspection Report Number <br /> - - - - <br /> ' State of California ; <br /> CIWMB <br /> grated Waste <br /> eManag) Survey Form - Page 1 ' j0 4 <br /> California Integrated Waste Management Board � V � V- 10 5 3 ..moi'- <br /> Part A curve BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: L� (} <br /> ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local f,E If Referral,choose referral type(Fill one) <br /> Identifier: t`'l,t f 1 <br /> ( !.t t-f 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - <br /> Busm - -- <br /> // Inspected By Inspector <br /> Physical Address -- — ............. <br /> -� r <br /> v"J <br /> Street J <br /> __, Inspection Date <br /> City r State ZIP Code Time In Time Out _ <br /> Business Rep Title 0 AM <br /> m 0 AM <br /> �= : LH O PM �1 O PM <br /> Operational Status <br /> . Business Role <br /> (Fill one only) (Fill all that apply) i(that aplye <br /> ® Active Generator � ) . <br /> GPS Latitude , LLLLClosed Hauler <br /> --- ( 0 inactive 0 <br /> Longitude - , IO 0 Planned 0 End-Use <br /> � wwm f 4 n t W ,YMs �"��'±^N4°.�P sg aKr f�.��p�r'b,'���y'��"`cb'f a'I t r � r "r"'u'n'�vy � '�r✓ n7 ''r s,�Y ' <br /> 0 New Tire Dealer 0 Auto Repair 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 <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 x 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 EDIIXII <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 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 <br /> 0 In Compliance - No Violations <br /> 0 Other: § <br /> omments jjssT i <br /> p J <br /> L-;t;U' S(� yJr.',r�% Vr�'�{l�' i4�{ <br /> r; ) `^ ri -L 4 ! r1 , h <br /> 6'o i—(( ? <br /> t J r <br /> tri C_ jtJC ,( �(�Y'tBtt � f(f o �1I`.•�'i.d (f (F•.)}'r ��;� C.dGI� l II Il�r <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X '�;, 1 -M � T 62081 <br /> ■ - -- © ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> I <br />