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Waste Tire Su y & Inspection Reporl.inspection Report Number <br /> 76.� State of California y <br /> California <br /> CIWMB181 <br /> Waste <br /> eManag) Survey Form - Page 1 I - Q <br /> California Integrated Waste Management Board <br /> Part A Survey BLUE OR BLACK INK PEN <br /> a� __ _ <br /> Inspection Details <br /> u <br /> TPID- _� Inspection Type (Fill one) <br /> Site Suffix: <br /> © Routine O Re-inspection O Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ? ✓ 0 CHP. mO CIWNtB Q.Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> L p!' <br /> Physical Address <br /> t I - - <br /> StreeI .t Inspection Date <br /> EIQ <br /> n <br /> EE <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM <br /> ( ( - © PM O PM <br /> 0 AM <br /> L <br /> t_ �L `,� Operational Status t� 4, ,�r�� "�t '� Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) <br /> 3 � � 0 Active �� s r' �'n �',�"�l 0 Generator O Outdoor <br /> 0 Closed '' ` <br /> Latitude � u' <br /> GPS Hauler 0 Indoor <br /> Q Inactive <br /> Longitude 0 Planned �� ��'z"�'� + � End Use 0 Container <br /> ".,�a:. . a.�.�_w— e�1^ rv�1u!._�.. fir !.....x:�i ...'��i°:. 4).. � .,. ,! .., .1 .u•Gr,"_.h. .fi+:,a..""NS�Y.7:vqt„f'f ci"..(' s. Si�Ps�: ">�s�Fk...e".�f:;, t,,, ,A __I <br /> Q New Tire Dealer Q Auto Repair O Trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer O Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> O Service Station O Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUSr <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation ° Q Extension <br /> O O 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 wh Manifesting Requirements Date m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> i <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years - —- -- - -- —- -- <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers j Q Referred/CIWMB Enforcement <br /> I <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 In Compliance - No Violations <br /> 0 1 0 1Other: § <br /> Comments <br /> Inspection Form Included: 0, <br /> Comments Included: 0 - _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X 1�, i. ;;;A 1,0,1 P, �I�, j 1 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />